In the UK the government are awaiting publication of the NHS 10 year plan. Neil Stewart, Editorial Director of the Maternity and Midwifery forum, reflects on current issues in maternity services, following viewing of David Attenborough’s, Oceans and attending the International Council of Nursing congress in Helsinki.
Many of us have looked at the recent David Attenborough programme on the Oceans and how human intervention and actions have dramatically changed the nature of life in the seas.
But what about our own species?
The shape of midwifery services for the next 10 years is being debated and ready to be given new direction and structure as part of the NHS 10 year plan.
In the next 4 weeks expect a range of announcements on all aspects of government plans mapping out how local government, justice, environment, and finally health services, will be delivered after the spending review announcements last week.
This week we have now heard from Wes Streeting that we are to have a short sharp Darzi style review of the 10 NHS Trusts where the most high profile failings in maternity and neonatal units have been highlighted.
In addition, the Secretary of State will chair a “taskforce” on maternity and neonatal units’ safety and improvement.
While this might seem exasperating after all the enquiries into Morecambe Bay, East Kent, Shrewsbury and Telford and now Nottingham, plus the extensive Renfrew report on maternity Safety in Northern Ireland it is to be welcomed – better to get it right than run with short term solutions. In focussing on maternity AND neonatal units he is following a key perspective from Renfrew, that their integrated working is critical to safety.
Importantly he intends to look for best practice and international examples of quality following more closely the model of the Renfrew report on safety in NI.
Importantly he talks about maternity and neonatal units together
Birth Trauma is up the public agenda after the publication of the book of Theo Clark, the former Conservative MP, on her experience and the experiences of many more, challenging the received ideas about childbirth and its aftermath.
The problem is that maternity services are being pulled in all sorts of different directions by a range of dramatic changes when looked at over the decades since 1950s – the same time David Attenborough has been looking at the natural world.
Maternity is being pulled into defensive medicine in response to the scandals and safety issues revealed in the various enquiries of which Ockenden was the largest.
It has been at the centre of a culture war over the use of the term “normal birth”, and some units have found themselves in the firing line over changing terminology about women and childbirth in an attempt to be inclusive. Wes Streeting highlighted the way in which women were being told they had a “normal birth” (baby and mother left the unit alive) when the birth had, in fact, been traumatic with physical and mental scars and tears not admitted.
The CQC has moved, raised its profile, with its school OfSTED like judgements on whether maternity units are “inadequate” or “need improvement”. This language has been widely interpreted by the press as over half, or nearly two thirds of units being “unsafe”, not something the CQC actually says. Streeting has put Mike Richards, a widely respected public health manager, in charge of the CQC which he also called a “failing” organisation. He admits the dilemma that these kinds of reports raise fear levels among pregnant women.
In maternity units the rate of induction is rising, and the rate of Caesarean sections is over 50% in many units, and predicted by the Obstetricians in the Renfrew report to be likely to rise to 60%.
With half of these being unplanned emergencies. This was not specifically addressed in the Secretary of State’s address to the RCOG on 23rd June but is bound to come up in the investigation and in his taskforce.
What the CQC does highlight, among many causes for concern, are staffing shortages. There is a big programme of work on retention and an age related bubble of staff approach retirement – but some is running up a down escalator.
In the midwifery schools’ problems of student drop out are rising, officially estimated at 15% not completing, but anecdotally rising. The shortages problem will not be solved without addressing this issue.
In London the birth rate has fallen so far in some localities that the closure of maternity units is now on the agenda at even major hospitals like the Royal Free.
Why do the delivery of maternity services and the experiences of pregnant women and new mothers seem so out of step with what is planned and expected by mothers for their experience of childbirth?
A week in Helsinki at the International Congress of Nurses acted as a reminder how many countries still have nurse midwives, that midwives cannot practice separately or often not at all outside hospital or “ medical supervision” and how varied the experiences of women are around the world. But many of their societies have better, maternity, neo natal family, social and government support from which we could learn.
We no longer have the practice of “lying in” keeping a new mother, together with other new mothers, in a unit, monitored and supported for up to 5 days as they still do in France and other countries, until the mother is literally “back on her feet” breast feeding and healing, and ready to go home. And how many scandal cases have involved a mother being sent back home instead of being admitted to the unit because of bed limitations, in a way that would not have happened decades ago. Since the MRSA scares over a decade ago UK hospitals policy has been to discharge as fast as possible.
Helsinki was a reminder how many societies seem to have maternity services that are much more in step with changing face of family life, social support, postnatal service and time off work. Services that wait for and work round the woman and baby and are flexible and surround a new mother and her child for weeks, in a way that seems to have been lost in the fast in, fast out, fast turnaround service in the UK.
Mothers and babies in the UK, going quickly out into isolated or fragmented homes, away from relatives, lacking support, with poor maternity leave from work, poor children’s services and business support or financial support in comparison to other countries.
Gone is lying in for 5 days, gone are lots of regular follow up visits from midwives, or health visitors, whose numbers have dropped dramatically, but most important gone are the wider family and community support that once surrounded a new mother for weeks: something that still does appear to happen through extended families in minority communities from Afro-Caribbean or Asian traditions, but even there it is fragmenting.
Into the middle of all this the midwifery hour had a fascinating presentation from the Professor of Anthropology at the University of Durham, Professor Helen Ball on breastfeeding, babies and infant sleep patterns. If you like David Attenborough’s observations on the natural world you will love this video. She looks at how theories, and official advice on breastfeeding and infant sleep patterns have changed with industrialisation and society change, producing theories on breastfeeding and infant sleep to meet the needs of modern work, rather than starting from and sticking to the needs of the woman and the infant and their physiological and neurological patterns.
And perhaps that is where any NHS review should start. A longer term anthropological and sociological look at how we treat and value the whole cycle for women of pregnancy, childbirth and infant growth – build our societies and services around that, not the other way round.
How have society policies in the UK and maternity services got to a point where the women and the baby needs seem to be required to fit to the rushed and crushed allocation of beds in hospitals, built for acute emergencies, with staff shortages, poor maternity services, defensive medical practices with a consequent rise in use of surgery, birth trauma and a declining birth rate?
When we reach the point where half the female of the species is giving birth by surgery perhaps, we need some long view anthropological reminders of how much we seem to have lost sight of in our own nature – not just on nature at the seabed.
Neil Stewart
Editorial Director, Maternity and Midwifery forum
June 2025