At the start of a new year, with a government looking for a plan, what of UK Maternity care? Neil Stewart, Editorial Director for the Maternity and Midwifery forum asks the Secretary of State for Health if he is resigned and comfortable with the rate of Caesarean section reaching 50% on his watch and asks what is the Big Ask for Maternity services.
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Dear Secretary of State
Are you resigned and comfortable being the Secretary of State on whose watch 50% of the female of the species give birth by major surgery with virtually no public debate on how this has come about and what it means for child and maternal health?
You have asked for submissions to your 10-year plan for the NHS. The condition of maternity services will be one of your biggest challenges, but not, perhaps, in the way you imagine.
You have inherited a maternity service under enormous pressure in practice, legal challenges and sustained criticism in the media as a crisis in safety. The warm public trust of Call the Midwife has been replaced with anxiety, stress and confused signals about the safety of childbirth and maternity units in the UK.
The Royal College of Midwives have made their submission detailing all the challenges and necessary solutions in staff shortages, student education, mental health, stress, retention issues and pay to improve the service for women.
Three big Inquiry reports lead the briefings new and returning MPs rely on from the House of Commons Library. These highlight Morecambe Bay, Shrewsbury and Telford, East Kent, and soon Nottingham, along with a health select committee report in the last parliament on maternal and infant deaths, an APPG on black maternal health, plus the 2024 APPG on Birth Trauma work from Theo Clarke, former MP and Rosie Duffield MP confirming birth trauma as a major issue emerging from stillbirth and maternal death enquiries.
Birth Trauma was also revealed in the long tail of complaints and stories presented to the Ockenden enquiry that, besides risk of stillbirth, neonatal and maternal death, a large and growing numbers of women were facing significant birth trauma, physical and mental during and post-natal, even though the recorded official statistics said mother and child left the maternity unit fit and well.
These revelations are now reinforced by the Care Quality Commission reports that over half the maternity units fall below one safety standard or another. There is a systemic safety challenge with repeated staffing and other shortcomings in UK maternity units and our system of childbirth is unsafe is the consistent message to policy makers and the public.
Safety, safety, safety runs the narrative and maternity units are now implementing a range of recommendations from the Ockenden report (but not all of them) and from NHS England to raise safety standards, report mistakes or incidents and reduce risks and trauma by learning from these.
The safety pedal has been pushed to the floor for several years. Will pushing it again be enough?
Because something else is happening in maternity services which urgently needs to be addressed with some public debate. The rates of induction of labour and then of Caesarean section surgery are rising fast but the improvements in stillbirth and maternal death figures have stalled and recently got slightly worse.
Are the two connected? You will want to know the answer before you double down on more of the same in maternity services. The drive for safety brings a risk averse culture, and early resort to interventions and birth by surgery. Midwife shortages increase the chance of problems being missed and emergency responses needed, less individual care and a sense of fear in mothers and midwives leads to increased trauma.
In your arguments with the Treasury for money for the NHS you will know that maternity litigation and awards for “mistakes” are the largest cost group (over £1.5 billion) in the huge bill your department has to pay in medical compensation each year.
You will be aware that while other parts of the NHS workforce have grown since 2010 by over 30% midwifery has grown by only 7%.
You will be told that 33% of births according to the last published statistics were by C section. What you may not have been told was that 121,000 of those were “emergencies”.
Since 2014 women have had the right to ask for an elective C Section.
In one year 90,000 out of around 600,000 women went into a maternity unit with a plan for an elective C section. Either by choice or mostly by agreement with the midwife and obstetrician that risk factors like weight, age, diabetes suggested a precautionary approach to birth method.
But 3 or 4 days later a total of 211,000 go home having had C Section surgery, 121000 of which are emergencies: all against the predictions of clinicians, midwives and the wishes of pregnant women. At the cost of potential huge trauma to women, and babies (many have breathing difficulties), and actual extra cost of an extra £250 million for the surgery with no clear figures on the cost of aftercare.
Strong anecdotal evidence from those on the front line is that many maternity units have already passed the 50% birth by C section marker.
You will share the worry of many researchers that these numbers may eventually be revealed to be in the areas of high deprivation, poverty and ethnic diversity.
You will be annoyed to find that one unhelpful and, self-serving, consequence of the media frenzy around the Morecambe Bay, Shrewsbury and Telford and Kent scandals was a decision not to publish individual maternity unit C Section figures.
The obvious rejoinder to all this would be to press you to launch an overarching Inquiry led by experts to look at these trends and make recommendations.
Such an Inquiry would need to look at all these issues in the round, start with the safety issue but look at the whole structure of maternity and midwifery services from homebirths, midwifery units to hospital maternity units and neonatal units.
It would need to be taking testimony from women, professionals managers, charities but with a particular mission to start from the wishes, expectations and needs of women not just the demands of the existing services and professionals which have brought us to this unhappy place.
And then develop a plan to transition to a new configuration of midwifery and maternity services.
But happily, you do not need to launch that because exactly such an inquiry has just been completed and published in part of the UK addressing all the issues you are facing.
The Renfrew Report on Enabling Safe Quality Midwifery Services and Care in Northern Ireland was published on 22nd October 2024.
This report makes flesh the current Maternity Transformation programme (Better Births 2016) to which your department is committed and answers the questions raised by the various safety enquiries.
In compiling the report, the authors liberally, and helpfully for you, include all the comparative figures for the other 3 nations, plus service examples of what works, giving a unique and evidence based argument for their conclusions.
They include the wide testimony and “listening” from families and professionals not just on where things were failing, but powerful testimony and examples of where services are working in the aspirations set out by government policy and international bodies over the last decade.
This meets the “what works” test regularly commanded by government. Don’t be put off by excuses that it was Northern Ireland Specific; the issues and challenges are recognisably the same, the lessons applicable and the solutions easily adapted to NHS England.
You will have to deal with rolling eyes and whistles of “here they go again, midwives wanting to be different and separate”.
But pregnancy, childbirth and postnatal care is different. The women are not sick, they do not have a disease, they are not an emergency, they are on a natural journey which most of their mothers and grandmothers were able to complete with midwifery support and without surgical intervention.
There is no waiting list in maternity services, there can’t be, but the health services do get 7- or 8-months’ notice. Pregnancy is not an emergency A proportion of pregnant women are at risk, (WHO estimates 10-15%) and we know how to predict, prevent and tackle those risks.
Watch out for the 600,000 births per year statistics, because that is really 1.2 million patients – mothers and their babies health in your maternity unit hands and too often the mother gets forgotten after discharge.
Women want choice but they also want to know that if events take a dangerous turn the services and skilled midwives are there to escalate and to protect them and their child. They want options for homebirth, community midwifery units, alongside midwifery units close to hospital back up and maternity units in hospitals for elective C Sections. They want their choices to be respected and met and resourced.
In the USA, with no universal midwifery service, you are 15 times more likely to die of pre-eclampsia, a particular risk in pregnancy, than in the UK. Midwifery services save lives.
Women want much better postnatal care and this must be one of the main challenges for the new Integrated Care Boards in England. The right start for mother and baby has proven livelong impacts and must be invested in.
The evidence is there in the report on what works, what is safe and how to roll it out and build it over 5 years.
- Start from what women want – and what repeated government policy promised to deliver but stalled in austerity and pandemic.
- Develop continuity of carer which is pregnant women’s consistent first demand
- Plan maternity and neonatal units and budget together
- Develop 3 year ring fenced budgets to provide stability and capacity for change
- Rebuild community midwifery and its relationship with general practice and health visiting for postnatal care.
- Put the staffing, education and skills training in place to make it work
The Renfrew report is a template for developing midwifery and maternity services across the UK and addressing some of the runaway trends in childbirth that are distressing women and professionals.
You may also hear from time to time the arguments about “lesser evil” and being precautionary. Medical advance can meet the need you will be told. C Sections are safe. But beware. Harvard University commissioned Dr Neel Shah and the Ariadne Labs to conduct a massive statistical survey of maternal health and morbidity in the USA going back decades. Published in 2017 the report found that in the highly medicalised and well-funded systems in the USA, “a woman was now 50% more likely to die in childbirth than her mother”
Renfrew can help avoid that scenario. I suggest it is incorporated into the NHS plan with the same imperative as Darzi.
And it would not be fair to leave without making a political point to a politician: before the next election there will be around 3 million births in the UK over 5 years, with 3 million partners, with millions of grandparents all paying close attention. With second and third children to the same parents that will still come to around 8-10 million voters with a very direct interest in maternity services, spread evenly around the UK.
Good maternity services matter to mothers and midwives. Good maternity services matter locally and electorally.
Neil Stewart
Editorial Director, Maternity and Midwifery forum
January 2025
1 comment
Well said Neil Stewart