Following the Ockenden and Kirkup reports, the AMOS review has once again exposed the deep-rooted problems facing maternity and neonatal services in England. As the Government’s new Maternity and Neonatal Task Force begins considering how to turn those recommendations into action, Neil Stewart asks a crucial question: who is in “the room where it happens” when the decisions are made? From staffing and the closure of maternity units to triage, bed capacity, the design of maternity environments and the forgotten concept of “lying in”, he argues that the next phase of reform must look beyond safety alone and rethink how maternity services are designed and managed around the needs of women and families.
Are we at a new beginning or are we going to start where we left off in the public debate about Maternity Services in June? Will the Secretary of State for Health, Yvette Cooper’s National Maternity and Neonatal Taskforce come up with decisive reforms following the AMOS Report?
Just as the Maternity & Midwifery Forum newsletter wound down for the summer in July the latest Ockendon report (on University Hospitals Nottingham) and then the AMOS report looking at issues across 12 maternity and neonatal units were published.
Both reports had powerful and painful reminder messages about the dysfunctional state of maternity services, the safety issues, the staffing problems, recruitment and retention, the cultural breakdown between staff and respect for women, in bullying, the shortages, the treatment of black and brown women, the 748 previous recommendations from previous reports. All reinforced with painful individual testimonials inevitably highlighted in the media. And the inevitable rerun of a row on Normal Birth ideology, which Amos said publicly she did not find.
But there were some welcome new proposals including the appointment of a Maternity & Neonatal Commissioner. The government have said that they are going to follow the AMOS recommendations which are now on the table for the Task Force, the commissioner, and the idea of a “no blame” mechanism like New Zealand which not only dramatically cut the NZ compensation bill in half but helped families come to terms with and move on from the tragedy, something our slow, litigation heavy process fails to do – indeed often makes worse the pain of loss. It also proposed the ideas that Maternity units, and theatres, should be staffed 24/7. How anyone ever thought babies planned their arrival according to Monday to Friday shifts is beyond comprehension, but she found theatres closed, staff levels cut as though it was a predictable production line.
Now we open the new autumn newsletter with newspaper headlines on the temporary closure of the North Devon District Hospital in Barnstaple maternity services due to staff shortages.
What benchmark were they applying since huge numbers of maternity units operate with staff shortages?
The CQC routinely list staff shortages as one of the reasons for judging 36% of maternity units “requires improvement”, and 12% were inadequate. So it is a big decision to close a maternity unit. Which brought up an interesting episode in another maternity unity enquiry into East Kent. They had shortages but when the local Head of Midwifery told management she thought the unit should be closed, she was over-ruled and tragic consequences followed. It did not, however, prevent the press lambasting the midwives for failures. So who decides? And when and where do they get to decide?
I ask this because it has been brought to my attention that the Chief Midwife, Kate Brintworth is not on the Maternity and Neonatal Task Force. There are members (Gill Walton from RCM) who are or have been midwives, but the Chief Midwife is not on the list. No doubt she will be advising, commenting, making input etc but she is the custodian of the existing maternity policy on paper including continuity of care.
As we all know from the politically inspired musical hit “Hamilton”, that what counts is who is in “The Room Where it Happens“.
This is important because not every policy maker and budget holder will be sorry that the maternity unit at Barnstaple has been closed. Maternity units are being systematically shut down across the land as the old local “infirmaries” that hosted them, are closed and services are concentrated – mostly for good clinical and capital spending reasons – in large acute hospitals.
There is, however, a large body of health management opinion that this kind of concentration in bigger acute units should be safer, certainly more cost effectives, and in large urban areas where most of us live, the distances will be no more than people travel to work, or college anyway. But even short distances do not prevent tragedies. And acute units do not come much bigger than Nottingham and Leeds whose last stats say they handled 8000 births (that’s 16,000 patients you must remind them).
All the feedback is that this concentration on Acute hospital sites does have consequences because more and more these maternity units, run as part of large acute hospitals , now have to run to the management metrics designed for significantly different kinds of clinical services.
The architecture looks increasingly the same, the rooms are not made for extras like waterbirth, multiple relatives, the beds are standard, the shifts and staffing plans and use of bank or temporary staff are centralised. And importantly the tyranny of admissions policy and “bed numbers” leads to constant shortages reminding us of what we see in the “trollies” in A&E. Despite heroic efforts in many units to reshape the rooms, change the lighting, set a different ambience, bring in appropriate equipment instead of always sharing acute hospital kit. You would think these pregnant women were ill or diseased.
And this is the problem, pregnancy and childbirth is not an emergency, it is a risk that most come through, services get at least 6 months’ notice but also pregnancy is not “cold surgery” planned to the day, morning or afternoon, but not night, and able to postpone if a staff member shortage hits, These two models dominate Acute thinking. Thus the constant attempt to schedule to a fixed “due date” as though it could be fixed in stone and is no more than a “best guess” when we know women can and do give birth safely between 38 weeks and 42 weeks for reasons still not fully understood, which is why midwives still enquire whether the woman knows if she was late or her mum was late. Delaying admission till the last minute, discharging as soon as possible – the average turnaround – in and home – according to Bill Kirkup is now less than 2 days. Our mothers and grandmothers would have experienced up to an average of 10 days or more if necessary which is the more realistic window.
Highlighted in both reports repeatedly is this question of failures in admission, triage, escalation, appears again and again influenced by shortages, lack of face to face time, reliance on calls reliance on temporary staff or less experienced gatekeepers. It is not the source of every tragedy but appears in the testimony of too many. Which brings me to the question that appears constantly in the chat at the bottom of newspaper articles like the recent Times article – Women shouldn’t have to fear giving birth (£) from Alice Thomson prompted by Barnstable and the huge distances pregnant women were expected to travel.
That question is “lying in” as it existed and was available when women were routinely admitted if they reported unexpected symptoms or changes, often days in advance, and were able to have bed to be monitored before and then expected to lie in for 5 days, recovering, doing pelvic exercises, latching on and then be discharged with post-natal visits from midwives and health visitors.
Did acute hospital bed management kill the idea of lying in? It still exists in other countries from a canvass I did of midwives at ICN congress in Helsinki last year. Slightly different forms, slightly different, usually better, financial support and surprisingly in the German case a midwife could visit every day after for 12 days including helping with domestic issue – usually sterilising and hygiene – but maternal support that must do wonders for mental health for which we now know this is a critical period, and not one to be isolated and alone.
So as the task force on maternity and neonatal services meets to go through the list of actions from AMOS to appoint a commissioner, initiate how to establish NO Blame, plan for 24/7 maternity service staffing they could add to the list:
A. Appoint our Chief Midwife to the task force so she is in “the room where it happens”
B. Review maternity Unit bed policy to create admission space for triage admission and escalation improvement in “the room where it happens”
C. Reinvent modern “lying in”, in “the room where it happens” for those who need or want it as part of postnatal review
D. Create the architecture of a birth centre not an A&E service in “the room where it happens”
Neil Stewart
Editorial Director,Maternity & Midwifery Forum
September 2026