Babies suffered fatal skull fractures as they were forced out of their mothers using forceps. Women were left screaming in agony for hours and were told by medical professionals that their agony was “nothing” and that they were “lazy”. Infants developed lifelong and life-changing disabilities as a result of terrible maternity care. Mothers were blamed for the death of their babies.
The findings of the interim report of the Ockenden inquiry into maternity care at Shrewsbury and Telford Hospital NHS trust are distressing in the extreme. The independent review is considering 1,862 cases, most between 2000 and 2019; it is likely to be one of the biggest healthcare scandals in the history of the NHS. Mothers and babies needlessly died and were left with avoidable and profound disabilities as a result of substandard care. In a breathtaking double injustice, it has taken an 11-year fight for grieving parents to get to the truth. They lack any assurance that this will not happen again. Parents are still fighting to get anything approaching minimum standard of care from underfunded services for their disabled children.
The inquiry report described a shocking catalogue of errors that were repeated again and again. There was a failure to properly monitor foetal heartbeats. Oxytocin – a drug used to increase the frequency and strength of contractions – was “injudiciously” used in cases where babies died or developed serious disabilities. Women were not directed towards consultant-led care when risk factors emerged in their pregnancy, and were inappropriately persuaded to attempt a vaginal birth. Babies born at home were not adequately monitored when they were showing signs of serious distress.
This is not representative of the care most women giving birth receive from the NHS. But neither is it just Shrewsbury and Telford. More than 1,000 babies die each year as a result of something going wrong in labour, and maternal mortality rates are worse for black, Asian and minority ethnic women. There is much in common between this review’s findings and those of the inquiry into baby deaths at Morecambe Bay NHS trust. An independent inquiry into maternity safety at East Kent NHS trust was launched earlier this year after the Independent reported that, between 2014 and 2018, 54 babies died within seven days of being born. All these tragedies share things in common with cases of systemically negligent care where it has occurred in other parts of the NHS, most notably in the Mid Staffs scandal. All reveal serious failings in leadership, a lack of compassion, cultures where staff are scared to raise concerns, a failure to learn lessons even after many lives are lost, and a disregard for relatives and survivors who are trying to get answers about what went wrong.
But some issues are unique to maternity care. There have long been failures in women’s healthcare, related to a predilection to focus on disease as it affects men. Conditions that only affect women, such as endometriosis and pelvic floor disorders, have been neglected by medicine. Substandard maternity services have not been scrutinised despite the many lives lost.
It goes beyond this, however: failures in maternity services have been related to an ideological aversion to medical intervention in birth in some pockets of the midwifery profession. For many women, a non-medical birth led by midwives will be a good and safe option. But it should be a woman’s choice. There are serious risks associated with inappropriately pushing women towards a midwife-led vaginal birth, and leaving medical intervention too late when problems arise.
That is what happened in Shrewsbury and Telford and in Morecambe Bay. In Shrewsbury, the review found women had no freedom to express a preference for a caesarian section: the culture was to keep caesarian section rates low “because this was perceived as the essence of good maternity care”. At Morecambe Bay, some midwives pursued natural birth “at any cost” and prevented doctors from intervening, and even assessing, women in need of medical intervention.
The midwifery profession has been far too slow and defensive in responding to these examples of dangerous practice. The Royal College of Midwives (RCM) only ended its 12-year “normal birth” campaign – which saw it encouraging mothers to give birth without any medical interventions including epidurals, inductions and caesarians – in 2017; even then it failed to acknowledge that in implicitly tarring medical intervention as “bad”, it may have played a role in maternity failings. The Nursing and Midwifery Council – which regulates midwives – spent £240,000 in response to a freedom of information request redacting information from a dossier it held on the patient safety campaigner James Titcombe, whose baby Joshua died as a result of failings at Morecambe Bay. Titcombe has rightly raised questions about whether the RCM is doing enough to challenge a misplaced commitment to natural birth among some of its members. The chief inspector of hospitals this year expressed concerns about a cultural division between midwives and doctors adversely affecting patients.
There have been some positive reforms since the Morecambe Bay inquiry: all baby deaths in maternity services are now investigated by the Healthcare Safety Investigations Branch. Mortality rates are falling. But the healthcare regulator this year reported that four in 10 maternity services do not meet the safety threshold of care. This is not good enough. NHS underfunding makes the delivery of safe care more challenging than it would otherwise be.
A century ago, about one in five women died giving birth. Medical advances have drastically reduced that number. But the Shrewsbury scandal shows that too many women still receive dangerous care that has no place in a modern healthcare system. Without more urgent reform, women and babies will continue to lose their lives as a result.