The narrative has changed, and midwifery is struggling to make its voice heard writes Neil Stewart, Editorial Director, Maternity and Midwifery Forum and MATFLIX. What is going on and how do we reverse the trend?
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When did it change – the public discourse about maternity and midwifery?
Under pressure.
When did it change- the public discourse about maternity and midwifery?
From high levels of trust and respect, media celebration of midwifery and medical successes with safer and safer births and falling mortality rates, to the mistrust and questioning by policy makers and commentators of maternity and midwifery services today.
The National Maternity Review in 2016, after the Kirkup Morecambe bay report, now seems a high point with its optimism and confidence in midwifery with proposals set out by the formidable Baroness Cumberlege, for continuity of carer, better recognition of mental health, better team working, the Saving Babies Lives Bundle and the objective of halving the number of stillbirths neonatal and maternal deaths and brain injuries by 2030. All seemed set fair for maternity services and midwifery to move forward.
This was mirrored, as so often, in popular culture with the decade of “Call the Midwife” portraying midwives with trust, insight, competence, and compassion, fighting for women’s voices to be heard.
Then slowly, step by step, report by report the mirror glass is broken, and public images of midwifery challenged with the findings and reporting of Ockenden into Shrewsbury and Telford Trust and subsequently East Kent.
The findings were terrible, and the reporting put a brutal and deserved spotlight on the treatment of those women, the losses of life but also on something new – the extent of serious birth trauma right along the system from early pregnancy miscarriages to postnatal support. A long tail ( 1390 out of the 1590 cases in Ockenden) were trauma related, of women experiencing not death or stillbirth, which were the initial focus of the enquiries, but terrible trauma before, during and after childbirth. Not only mortality among mothers and babies, but dreadful episodes of cover ups, gaslighting traumatised mothers, denial of mistakes, legal obfuscation, neglected long term morbidities in numbers of women, administrative and communications failures, bullying among staff, toxic cultures, lack of teamwork and terrible blame cultures, all culminating in tragedy and trauma that could, and should, have been avoided.
This was all accompanied by statements that these are not likely to be isolated cases and pointing to the CQC findings that 42% of maternity units are not up to the standard expected.
After Shrewsbury and Telford and East Kent to be followed in the future will be Donna Ockenden again on University Hospitals Nottingham, and every local and weekly newspaper is now calling out for cases where parents have not been happy with their care, and the lawyers have developed their case models.
Yet the national maternal mortality and still birth figures keep improving, maternity and midwifery have shown resilience through the horror of the COVID pandemic, but that is no longer the public perception or the public focus.
Something fundamental has changed in public, commentators and policy makers discourse and attitudes to maternity and midwifery services. The narrative has changed, and midwifery is struggling to make its voice heard.
What are the turning points?
Was it the statistics in the league tables that showed that the UK would have 1000 fewer still births if we matched Sweden’s services? Was it a realisation that the UK was not top of the European league table? To fall behind Nordic efficiency and spending in Sweden was one thing, but to be performing behind Poland and other eastern European countries was a shock to policy makers.
Was it the realisation that maternity legal cases, especially brain injury settlements, accounted for almost £1billion of the £1.5 billion compensation across the whole health service?
Or was it earlier in media reports around Morecambe Bay, or of comments about modern women being “too posh to push” and the accusation that some midwives were pursuing “normal birth”, vaginal birth to the point of risking mothers and babies’ health in a competition to reduce Caesarean sections? Was it that women were being denied the choice of a C-section or being disrespected?
Was it the treatment of women and their partners (especially the exclusions), during COVID that broke some bond of compassion, of common sense, that maternity staff were not putting pregnant women first?
In different ways with different audiences, it was all these things. This is how a perfect storm builds.
For the policy makers it was those statistics on still birth comparisons with Sweden and the huge compensation costs.
For traumatised mothers it was growing questions raised in the media about their treatment being channelled into an idea that midwifery might not be working to the woman’s agenda, respecting their choices.
All against a background of constant news stories of real individual and family tragedy.
Now, however the cry has gone up that “something must be done”, the most dangerous cry in public policy making. A show of action must be made. Someone must be at fault and to blame. Someone has to pay. The victim must always be believed.
The victim must always be heard, but their solutions or where they lay the blame is not so straight forward.
The current chancellor Jeremy Hunt, as previous Health select committee chair, ran with the argument that “normal birth” had become an ideology, with the implication that those who worked toward that, were “ideologues”, inflexible, disrespecting women, denying the choice of C-sections.
C-section reporting is not to be used as a management target, which must be right, but the suggestion that figures should not be published at all is not acceptable and hardly the new world of transparency.
The latest figures say that 13% of women go into their maternity unit with a pre-planned C-section and 33% come out having had one.
The medical and midwifery advice and the woman’s choice have generally been planned in advance.
On 591,000 births that is 76800 planned C-sections. But 4 days later 33% of women have come out of the maternity unit having had a C-section. That is 195,000 or 118,000 more than was planned or foreseen or agreed with the women. Whatever happens in those 4 days to change those plans should be a focus of debate but it does not suggest a lack of choice on C-sections for women or maternity services holding back.
Following Morecambe Bay changes in the supervision of midwives were put in the hands of Trust management, along with tighter real time reporting of incidents and accountability with the extraordinary fine of East Kent (to which they pleaded guilty) of £730,000. A combination of management drivers and incentives that is in its early stages but will hopefully see a marked improvement in outcomes, or it may risk a descent into more defensive medicine.
Now we are seeing the “pause” button being pushed on the Maternity transformation roll out of continuity of carer as the service copes with a severe recruitment and a bigger retention problem. This breaks an important promise on personalised care that midwifery has aimed to make to women and that women repeatedly say is critical to their good experience of childbirth.
Against the background, the core statistics at the centre of Better Births are continuing to improve but a new front, a new debate on every point on the childbirth journey is underway, not least the disparity figures which show that black and brown women are 4x or 5x as likely to die in childbirth. The focus is widened to the whole experience of childbirth, the narrative is changing and midwifery and maternity services finds itself in the firing line and on the defensive.
Where will all this lead? If we go down the America route will we heed the warning from Dr Neel Shah from the Ariadnne Labs at Harvard, charged with crunching the numbers in the US system, who found that a woman in the USA was now 50% more like to die in childbirth than her mother or grandmother? Is this increased medicalisation or changes in lifestyle, the argument goes on?
As we approach the Climate Change Summit in Egypt, when the world tackles the impact on the natural world of our once lauded policy on chemicals and agricultural interventions, the Egyptian minister of health has just had to issue a plea to the medical profession to change course because the C-Section rate has reached 75%. Do we really know what the long-term effects of our current models will be?
Sticking with Better Births (and Best Start in Scotland) still looks the best strategy for midwifery, but in the midst of a financial and recruitment crisis and a sharp change in public attitudes as new failings and bad practices are revealed, midwifery will need to speak up, deal with the new challenges and push back against any drift in policy. The profession needs to trumpet the successes for the vast majority of women experiencing childbirth in the UK but as we all know good news does not make headlines.
Neil Stewart
Editorial Director, Maternity and Midwifery Forum
November 2022