Safe birth over normal birth: why we must listen to and empower mothers

In December 2020 an interim report by Donna Ockenden, Senior Midwifery Advisor to the Nursing and Midwifery Council, was published on the inquiry into the Shrewsbury and Telford Hospital NHS Trust (SaTH) maternity scandal.

The Ockenden report’s findings about standards of care for mothers and babies

The report is full of deeply sad stories of bad outcomes. These include:

• failures to monitor babies’ heart rates and escalate concerns, resulting in stillbirth;
• failures to identify and act upon abnormalities on continuous traces, resulting in severe brain injuries to babies, and sometimes death;
• long labours, which mothers felt were due to a wish to keep C-section rates at the hospital low;
• excessive use of forceps resulting in traumatic injury; and
• failure to adequately monitor a mother as staff were “busy”, resulting in a brain injury to the baby and its subsequent death.

Another finding was themes of a reported lack of kindness and compassion. The fact that this had been found to be lacking was noted as “unacceptable and deeply concerning”. It was reported that there were even occasions when women were blamed for their loss.

Recommendations made by the Ockenden report to improve maternity services

The Ockenden report set out immediate and essential recommended actions to improve maternity services across England.

These recommendations included:

• enhancing safety;
• ensuring multidisciplinary training;
• putting in place robust pathways for complex pregnancies; and
• listening to women and their families, and ensuring women have ready access to information to enable their informed consent about their place and mode of birth.

In response to the Ockenden report, Nadine Dorries, the Minister of State for Patient Safety, said: “There is only one birth, and that is a safe birth… Every woman should have the birth she wants, which is safe for her, in consultation with her midwives, her obstetrician and gynaecologist.”

The dangers of a ‘normal birth’ and resistance to C-sections

The Ockenden report is presented on the background of a culture of pressure on mothers to give birth a certain way; a way that can sometimes result in tragic consequences. This was evidenced by the previous high-profile investigation into the Morecambe Bay maternity scandal, which found the deaths of 11 babies and one mother were avoidable.

When Donna Ockenden gave evidence to the Health and Social Care Committee in December 2020, she stated:

“We have spoken to hundreds of women who said to us that they felt pressured to have a normal birth. My clinical team said they have seen examples, even in situations where a normal birth in their own hospital would be contraindicated, of women being pressured to have normal births… It is important to say that at that trust there was a multi-professional…focus on normal birth at pretty much any cost. It is very clear… that there were times… when had a baby been delivered by a caesarean section the outcome may well have been better, and almost certainly would have been safer.”

The concept of a ‘normal birth’ is not a new phenomenon. The Royal College of Midwives’ campaign for ’normal birth’, which ran for around 12 years, defined a ‘normal birth’ as one without pain relief, instruments, induction or surgery. A key finding in the Morecambe Bay investigation was that there was a group of midwives, so cavalier they became known as “the musketeers”, who pushed for natural childbirth at any cost and refused to call doctors when necessary.

In 2017, it was announced there would be guidance for midwives to stop using language that would push women into births without medical intervention as this could put babies at risks, particularly where it made women feel reluctant to ask for help. The Chief Executive of the Royal College of Midwives at the time said it was inappropriate to push any agenda of their own on pregnant women. It was noted that a change in practice was required where a “value judgment” was being placed on women who asked for pain relief or a C-section.

Concerns raised about Shrewsbury and Telford Hospital NHS Trust

Concerns were first raised about SaTH in 2009 when baby Kate Stanton-Davies died six hours after birth. Midwives had ignored her parents’ concerns and failed to realise the pregnancy was high risk. Just a few years later, in 2015, Hayley Matthews’ baby Jack died when his mother was repeatedly refused a C-section.

In 2018, when concerns had been raised about SaTH and the Ockenden inquiry had begun, the Trust dismissed claims of further cases being uncovered as “irresponsible and fear mongering”. At that time, around 60 cases were reported: the Ockenden inquiry is investigating over 1,800.

Research into maternal care decision making

In 2020, charity, Birth Rights, undertook a survey to coincide with the anniversary of the landmark Montgomery v Lanarkshire judgment, which held that patients should be informed of all material risks relating to their care.

The research found that 61% of mothers said they would have liked more information to help with decision-making about their care and their birth plan. Only 45% of respondents felt they had been the primary decision maker in their care. Research undertaken by Birth Rights in 2018 also found that only 26% of Trusts were following national guidance on maternal requests for C-sections, and 15% had policies or processes that explicitly did not support maternal requests.

Indeed, at Shrewsbury and Telford Hospital NHS Trust, C-section rates were considerably lower in comparison to other NHS Trusts. This shows a great deal of room for improvement in informing women about their choices and empowering them to be central to their own maternity care.

A defensive culture

Bereaved father, James Titcombe, whose baby son Joshua died at the Trust, uncovered the Morecambe Bay scandal and has campaigned tirelessly for safer maternity care since, including changing birth terminology. It was revealed in 2017 that the Nursing and Midwifery Council had spent almost £250,000 redacting documents about how they had monitored him and his campaigning for nearly a decade.

The Telegraph recently reported the NHS has spent £30 million on preparing staff ahead of inquests into patient deaths involved in a series of hospital scandals, despite the Morecambe Bay Inquiry recommending measures to prevent NHS Trusts coaching witnesses and fending off inquests.

This history is uncomfortable when considered beside recent calls for blanket immunity to clinical negligence claims arising during the pandemic, and complaints from the defence union community about the cost to the NHS of claims. The disturbing findings of the Ockenden report serve as a reminder of the catastrophic consequences of clinical negligence and why it’s important that patients and families retain this vital route to access justice through the investigation of a civil claim.

Blog | Weighing the cost: why the human cost of clinical negligence is more important than the bill

Future improvement of maternity care

The hard work of campaigns for patient safety do make a difference. On 24^th February 2021 the ONS reported that, in 2019, the stillbirth rate in England was the lowest on record.

The Royal College of Gynaecologists is running a consultation on their patient information leaflet on C-sections. Ideally, this will receive important input about championing women in their own-decision making. You can read the draft leaflet and give your feedback (before 5^th March 2021) here.

Another recent development in the pursuit of safe maternity care is the landmark CQC decision to prosecute an NHS Trust for the wholly avoidable death of baby Harry Richford. You can read our blog about that case here.

The Ockenden Review report contains some really harrowing stories of failed parents suffering unimaginable loss. A culture of poor care, repeated mistakes, failure to learn lessons, lack of compassion and resistance of any investigation/oversight is completely unacceptable.

Whilst we acknowledge the review findings must be extremely hard for the families, we welcome the recommendations for change and hope they are implemented as swiftly as possible. Patient safety must be absolutely paramount and improvements made to ensure the well-being of mothers and their babies. Women should be central to their own care: informed, heard, empowered and supported in making choices that are safe and best for them and their baby.