In March 2015, the Morecambe Bay Investigation, chaired by Dr Bill Kirkup was published. The report concluded that a ‘lethal mix of failures’ contributed to the avoidable death of mothers and babies at Furness General Hospital (FGH) between 2004 and 2012. A major theme identified was that maternity care became “..strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care”. The report quotes one midwife who said during her evidence ‘..there were a group of midwives who thought that normal childbirth was the… be all and end all… at any cost…’.
Concerns relating to the influence this approach had on the safety of maternity care at FGH had been raised by parents long before the Kirkup report was commissioned, but the report’s publication resulted in a renewed focus on the issue and in particularly, on the Royal College of Midwives (RCM’s) ‘Campaign for Normal Birth’.
In 2017 the Times newspaper reported that the RCM would be formally ending their decade long campaign, a move that was widely welcomed, by families and charities but which also prompted a backlash from some elements of the midwifery community. Indeed, some claimed that the news reports suggesting that an ‘ideology of normal birth’ was impacting on safe maternity care were ‘…fear-mongering untruths, aimed at damaging a profession, and limiting women’s autonomy and choice’ and on occasion, bereaved parents speaking out about the issues were vilified as being ‘…on a mission to demonise all midwives…’.
The furore that followed prompted Dr Bill Kirkup to write in the Health Service Journal calling for unity, balance and clearer messages around the debate.
A focus on safer maternity care
In the years since there has been a considerable national policy focus on improving maternity safety with clear evidence emerging that in some key areas, for example stillbirths, that outcomes are improving.
However, despite some positive progress, the Care Quality Commission warned last year that maternity services stood out as:
‘…one of the core services we inspect that is not making improvements in safety fast enough’ stating that ‘…issues identified in the 2015 Kirkup report – staff not having the right skills or knowledge; poor working relationships between obstetricians, midwives and neonatologists; poor risk assessments; and failures to ensure that there is an investigation and learning from when things go wrong – are still affecting the safety of maternity care today.’
In addition, new major independent investigations into the safety of specific maternity services have since been established.
In December last year, Donna Ockenden published an initial report into the first 250 clinical cases (from a total of 1,862) relating to poor maternity care at the Shrewsbury and Telford NHS Trust.
Giving evidence to the Health and Social Care Committee in December, Donna Ockenden 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.”
These comments are virtually identical to those of Dr Kirkup 5 years earlier. But could it be the case that Morecambe Bay and Shrewsbury and Telford were ‘one offs’?
In September last year, Prof Ted Baker, CQC Chief Inspector of Hospitals in England was asked during a Health and Social Care Committee hearing whether campaigning around ‘normal birth’ had had consequence for maternity safety more widely:
“It has in some cases. Dr Kirkup identified it at Morecambe Bay as a big issue, and we have seen it in other maternity services. There is sometimes tension between those who are proponents of what they call normal birth and those who are proponents of a more interventionist approach…When it becomes a tension between different members of staff—someone who wants to promote a normal delivery and someone who wants to be more interventionist—it becomes a cultural issue within the team, rather than people working together to do the right thing for the woman and her baby.”
Safe maternity care – a growing consensus
The high profile of maternity safety in recent years has resulted in a welcome focus on increasing evidence and understanding of the factors that impact maternity safety and the potential solutions by the academic and research community. Themes identified include ‘…a bias against complexity…’ and a ‘…professional bias towards the normalisation of pregnancy—with potentially catastrophic consequences.’
In September last year, the THIS Institute published a new framework outlining seven features of safe maternity care, based on a large multi-site ethnographic study and stakeholder consultation. The framework provides an important opportunity to build a consensus across the wider maternity system, including ongoing national policy work and regulatory focus.
Promoting teamwork and close multi-professional working
The 2008 Kings Fund report ‘Safe Births – Everybody’s business’, explored the issues around safety culture in the labour ward:
‘One consultant obstetrician with a specific interest in safety told us that the strong emphasis on normality in maternity services and the relative rarity of adverse events made it difficult to promote a culture of safety awareness on the labour ward without being perceived as alarmist and over-medicalising.’
‘We were told that the polarised views of some sections of the midwifery and obstetric professions, and their differing emphases on promoting normality or intervention, may have exaggerated the differences between the professions. We also heard that the majority of professionals working in maternity services hold more balanced views, but that these views can be drowned out by the more vociferous minority.’
’Crucially, we were told that this debate may be distracting professionals and others from the central issue of building effective teams that can ensure safety for mothers and babies.’
Events at both Morecambe Bay and Shrewsbury and Telford demonstrate the grave consequences of promoting ‘normal birth’ to the detriment of safe care and the importance of promoting a culture that supports close multi-professional teamwork.
To their credit, the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) have now committed to speak with one voice on maternity safety, affirming a joint goal that ‘…every woman should have a good birth, with the best possible experience and outcomes for mother and her baby.’
Oral evidence provided to the Health and Social Care Select Committee’s ongoing inquiry into maternity safety in England confirmed that national organisations including the DoHSC, NHS England and the Nursing and Midwifery Council no longer use the term ‘normal birth’. Sarah-Jane Marsh, chair of the National Maternity Transformation programme described the phrase as ‘..incredibly unhelpful’, a view which it seems is shared by many women and families as well as healthcare professionals.
Despite some efforts and messaging from national organisations, wider messages that emerge from influential voices from within the maternity community in England often feel contentious and divisive.
The UK based midwifery organisation ‘All4Maternity’, have published a commentary arguing that ‘… risk-averse healthcare, and contention over the use of terms like ‘normal birth’, have contributed to a rapid reduction in the opportunities for women and childbearing people to experience normal physiological birth.’
In relation to Morecambe Bay, the article argues that…
‘…despite more than 40 recommendations that emerged from systemic failings, across all disciplines… the media chose to focus on one statement: a drive from midwives of ‘normal birth at any cost’ which led to ‘demonising the promotion of normality’.
The piece argues that
‘…public perception of … the role midwives play has been eroded consistently in the media since the Morecambe Bay report…’ and finishes with a call for midwives to ‘..step up to the challenge to be changemakers as the guardians of normal birth.’
Such messages are not only deeply hurtful to the families of mothers and babies who died in part as a consequence of the approach to normal birth identified at Morecambe Bay and elsewhere, they also promote the divisive notion that ‘normal birth’ is something that needs to be actively guarded by midwives – when the focus surely ought to be on the multi-professional team providing safe and personal care – working together in the interest of all women and babies.
There have now been two major maternity investigation reports in England where an inappropriate focus on promoting ‘normal birth’ has been identified clearly and unequivocally as a major factor in what happened. Separately, the language of ‘normal birth’ is now recognised as being divisive and unhelpful. Given this, there seems to be an urgent need for a clear consensus position to be agreed and published so that messages moving forward are unambiguous and clear. This must also be reinforced through obstetric and midwifery education and ongoing professional training and development.
Unless this happens, mixed messages will prevail, continuing to cause hurt to bereaved families caught up in the crossfire and more importantly, filtering through to front line maternity services and contributing to inter-disciplinary tension and poor team working. If left unchallenged, sooner or later the inevitable consequence will be yet another major catastrophe.
James Titcombe – Feb 2021