Much proverbial ink has been spent this week responding to the first report from the Ockenden review into maternity services at Shrewsbury and Telford NHS Trust. Finding something new to say to another heartbreaking report into maternity services is challenging and yet the depth and scale of the harm done to families demands a response. Ockenden herself made clear that there was little in this report that had not emerged in previous reports or investigations whilst stating her determination that this time recommendations must be implemented. The report sets out 27 actions for the trust itself and 7 for the wider maternity system. We suggest that at the heart of these lie just 2 actions – and they both involve listening.
First of all we must listen to women. Our survey conducted with Mumsnet earlier this year to coincide with the 5th anniversary of the landmark Montgomery vs Lanarkshire judgement, confirmed that we are still a long way from a maternity culture that recognises that the person giving birth should be in the driving seat when it comes to decisions about their care.
The survey found that 61% said they would have liked more information to help them make decision about their care and planning for birth. And only 45% of respondents felt like they were the primary decision maker in their care.
It is important to point out that this applies no matter what women are asking for. One of the issues identified by the review team was that women “appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery”. Caesarean rates were significantly out of line with other Trusts locally and nationally and the low CS rates were worn as a badge of honour by the Trust. Donna Ockenden was keen to point out that this culture was pervasive throughout the team and was not a matter of midwives pitted against doctors. In 2018 Birthrights highlighted that a worrying number of services see discouraging caesareans as a matter of professional pride (our maternal request caesarean report found only 26% of Trusts following the NICE guidance on maternal request caesarean). We have seen first hand the lengths that women have to go through to be heard when they request a caesarean section, and have vocally campaigned for their right to do so. A target caesarean rate should never be prioritised over an individual woman’s care.
However, it is incredibly important to recognise that the majority of women who want a straightforward vaginal birth also find it very hard to be heard. We are contacted day in day out by women/birthing people who have to fight incredibly hard to fend off intervention they do not want: women who are told they are “not allowed” to have a home birth (only 38% of individuals in our survey with Mumsnet were told about the benefits of home birth compared to 61% who were told about the benefits of hospital birth) or to give birth in a birth centre even when this is an informed choice. People are surprised to find they have been booked in for an induction without any discussion whatsoever. Women who are told that if a baby is not born within a given timeframe they will need to have an assisted birth or a caesarean. We see cases where consent has been explicitly withheld and yet the subsequent intervention undertaken has been condoned not only by the Trust concerned, but by regulatory bodies as well. Human rights centred care demands that every woman/birthing person is listened to and respected, and maternity services must serve all those making a whole range of choices equally well.
Secondly, we must listen to staff. One of the hardest things to read in the Ockenden report, was the lack of kindness and compassion from staff. No one who enters a career in maternity care, does so with the intention of causing harm. So how do people who have entered a caring career end up blaming women for the deaths of their babies? Before we turn on individuals we should remember that we are all just as fallible in the face of a system which makes it impossible to act in accordance with our core values, resulting in “moral injury”. Burn out or developing a hardened shell are the most common responses to this internal conflict. And this is happening to staff right now in every maternity unit in the country.
The first step back from the abyss is to resource maternity services properly. A recent survey by the Royal College of Midwives found that over 80% of midwives did not feel they had enough staff to provide a safe service. And the Royal College of Obstetricians and Gynaecologists say that to deliver the Ockenden report recommendations the consultant workforce would have to increase by around 20%. Having enough staff in the first place is key to staff having the time to do multi-disciplinary training, conduct investigations properly or even just take a break now and then. Only staff who feel human themselves can offer humanised care. Recruitment and retention of staff in maternity services must be addressed as a matter of urgency.
We wish Donna Ockenden and her team the very best with the rest of their investigation. We are heartened that listening to families is at the heart of the ongoing inquiry. Listening to those giving birth and those caring for them is the key to changing maternity services for the better.