Three Enquiries and a Culture War – Untangling the Real Crisis in Maternity Services

This week the Maternity and Midwifery forum has been in Edinburgh for the final festival of the year. At the same time midwifery has reached the press yet again, with challenges to midwifery education prompting reaction from the NMC and Vice Chancellors. Neil Stewart, Editorial Director, Maternity & Midwifery Forum, reviews talks from the festival and challenges LME’s to respond.

It has been a revealing and slightly depressing two weeks for maternity and midwifery professionals – but has ended with high note with two keynote presentation at the Edinburgh Maternity and Midwifery Festival which explain graphically and put in context how we have got into this public mess in maternity services and how the trust of women in maternity services has been so damaged.

Across the UK maternity services are now the subject of three national enquiries, one each in Scotland, Wales and England. NI Ireland had their’ s published in October 2024 led by Prof Mary Renfrew. The Northern Ireland Review is the latest in a decade long line of reviews from Bill Kirkup 2014 on Morecambe Bay to Donna Ockenden on Shrewsbury and Telford, and now Nottingham, into English units. Baroness Amos looking for quick answers in 14 named trusts.

The Renfrew Report on NI was the first to adopt the kind of methodology ( looking at good as well as bad, comparing internationally, engaging with complainants and victims, reviewing the research, engaging clinicians), suggested by Kirkup and the prolific health blogger Roy Lilley in their recent podcast on maternity services and it maps out constructive answers – spoiler alert – there is no quick fix: just hard detailed work turning around a super tanker of a service.

Untangling the state of maternity Services

One consistent theme in deaths and birth trauma of women being sent home, even at 42 weeks in one recent case, has clearly more to do with lack of beds, reduced facilities, isolated, busy or lack of staff than any ideology.

The vast majority of women express a desire, a choice, of a natural physiological vaginal birth, and for those who want a C-section the law and guidance is now clear since 2014 that they can have that on request – and they do. The questions the consultants and midwives ask are their professional duty, not some conspiratorial pushback because of ideology. And the figures reflect this.

At the last published annual numbers of births in England around 90,000 women out of 600,000 pregnant women made the choice of a C section, usually with advice to have a C section from midwives and consultants. But after 2 or 3 days in a maternity unit 211,00 had a C Section – 121,000 emergencies- on top of 90,000 planned.

What happened in that short time to change everything about the women’s choice that was already accounted for: obesity, age, co morbidities, diabetes risk etc?

And why is the rate going up across all age groups, not just the older, less fit?

That is the question that should be asked. That is the question the women’s movement will get round to asking, and when it does, the answer is clearly not “by women’s choice”.

Contrary to the claim of not enough escalation intervention we are now in the position of over 50% of women giving birth by C-section in the UK. 50% overall – 121000 more than was planned and agreed beforehand by the woman, being escalated to and giving birth by abdominal surgery, with virtually no public debate on how this has come about in the past decade.

The last published figures in England were 44%, but every midwifery leader I speak to say the figures have gone over 50% in their units and, in the NI report, the medics predicted it would go up to 60% – these are the real issues behind the huge pressures on maternity units.

The sources and evolution of this change are clearly set out in two presentations in Edinburgh which I recommend everyone to watch to understand the organisation and policy dynamics of how this has evolved over recent years.

A change that has happened in less than one generation of women, possibly the biggest biological, chemical, evolutionary change in the process of birth of the female of the species along with the invention and roll out of the contraceptive pill from the late 60’s.

Two must watch presentations – how we got here.

Disadvantaged women in Scotland are living shorter healthy lives what can the intervention of midwifery do – Jaki Lambert, RCM

Jaki Lambert, Country Director, Royal College of Midwives looks at the evolution of maternity care through an interesting lens, asking if anyone had proposed moving to a planned system where abdominal surgery was increased to 50% among the 45 thousand women who give birth in Scotland; what would the managers have said – yet that is what we have got to in a completely unplanned and undiscussed way.

Postnatal care: Checklist or choice – Professor Helen Cheyne, University of Stirling

Professor Helen Cheyne, Professor of Maternal and Infant Health Research, University of Stirling; Deputy Director, Nursing, Midwifery and Allied Healthcare Professions Research Unit looks at post-natal care and highlights the sources of rising discontent among women at post-natal support available to them. She shows how discharge times have reduced to below 2 days, ever after surgery from 6 days, something still practiced by choice in other European countries.

In all this one key voice is missing, the voice of the women’s movement. Just as with the “trans” issues, it seems that voice is quietened or silenced from a sense of campaign affiliation with the historical demand for choice and respect for individual women’s identity, to be listened to, a distrust of hierarchical professionals, a history of patronising professional midwifery and medical practices, a long fight for women’s choice, choice to go home, a choice to have a C-section combined with growing stories of experiences of birth trauma that are now recognised as much more widespread and long lasting than the exceptions many once thought.

Unless all these enquiries can address the growing issues and problems identified by these speakers the service will continue to make ugly headlines.

While we have your attention vice chancellor.

Last week midwifery schools were the subject of a letter to Vice Chancellors from the NMC asking that they check that all their midwifery schools were following NMC standards in education and in addition to check up that none of them were preaching “the ideology of normal birth”,and given a month to respond.

The implied criticism in the “normal birth” campaign was that midwives were routinely and systematically denying women access or escalation to life saving emergency care and C-sections and now the finger is being pointed at universities and midwifery education.

While there are many, too many, examples of mistakes, missed diagnosis and failures to escalate to medical care and intervention, by medics not just midwives, the campaign connection accusing staff of an “ideology of normal birth”, is now understood to be a major contributor to defensive practice. This appears to have led clearly to the current trends affecting women and babies care and post-natal health .

Yes, there are organisations out there in the USA and other places that believe in absolute free birthing and are hostile to medicine as well as medics and midwives, but they are not part of the mainstream of UK care. Accidental and inappropriate links to websites that link to other websites without checking is not hard evidence of systemic ideological obsession.

Such was the panic this NMC letter instilled in vice chancellors breasts that a variety of memos were dispatched to puzzled and startled Health and Social Care Deans, chief nurses, chief midwives, HR, PR, and some directly to the Lead Midwives for Education (LME) for urgent answers – onto LME s with a fearful and accusatory tone of panic after which, on reflection, I expect many will be embarrassed.

You would have thought that after the mess university vice chancellors got into over “trans” inclusive issues and the definition of a woman, with the persecution of professors, such as Kathleen Stock at Sussex, they would have learned not to overreact to targeted news stories reviving the culture war over “normal birth”, which has rumbled for over a decade with huge unintended consequences in maternity services.

Or that trusts, realising that eradicating the term woman from all maternity websites was hardly inclusive, more confusing or dangerous. They should all be cautious of jumping into the next culture war over words with demands to “use our words not their words or be cancelled” as it usually comes back to bite them.

As for the one-month investigation into Maternity Education, one suggestion is that LME’s should reply by simply saying:

“Thank you, vice-chancellor, yes of course we abide by NMC standards, we don’t mess around with professional practice standards.

But while I have your attention, I wonder if you could investigate and answer how, in universities the midwifery teaching staff student ratio which used to be 1–11 has slipped to many averages over 1-20, and in the worst case we have heard, to 1-38.

Then can you look at how you and your colleagues have allowed academic midwifery lecture’s salaries to fall up to £15,000 behind the equivalent posts they get with their qualifications in the NHS. This is making staff recruitment and retention a nightmare,

Plus, can you ask your partner NHS trusts for nursing and midwifery why some midwifery students are not seeing a birth on a maternity unit in their first year and third year students are struggling to attend the statutory 40 births to meet NMC standards and having to extend for reasons that have nothing to do with our teaching”

Just a thought – best not to cower in front of this type of thing.

Neil Stewart
Editorial Director, Maternity and Midwifery Forum.

November 2025