The ambition for change
In the wake of the Morecambe Bay Investigation report (2015), the need to improve the safety of maternity services in England has been at the forefront of national attention. Following that report, the UK government’s commitment to halve the rate of stillbirths and infant deaths by 2025 underscored the urgency of the mission.
9 years later, despite commendable initiatives such as the establishment of a National Maternal and Neonatal Health Safety Collaborative, the appointment of Maternity Safety Champions and an independent programme of maternity safety investigation, the journey towards achieving these objectives remains fraught with challenges.
Where are we now?
Relative to 2010 rates, interim targets to reduce stillbirths and neonatal deaths by 20% were met in 2020 – a significant and commendable achievement that translates to 100’s of lives saved. However, both stillbirth and neonatal death rates increased again in 2021 and according to recent independent analysis, the 2025 targets are not on track to be met. The latest report from MBRRACE show that in 2020-22, maternal death rates shot up to levels not seen for 20 years – a jump of 20% from 2017-19 (and a sharp increase even when adjusting for Covid related deaths is taken into account).
Recent independent investigations into maternity services, notably the Ockenden report on failures at Shrewsbury and Telford, and the inquiry into maternity services at East Kent in 2022, have revealed alarming trends with findings not dissimilar to those found in the Morecambe Bay Investigation seven years earlier.
Despite efforts to improve, findings from the Care Quality Commission paint a sobering picture, with two-thirds of maternity services rated as either ‘inadequate’ or ‘requires improvement’ for safety.
The cost of harm
The financial toll of clinical negligence payments relating to maternity care is staggering, with NHS Resolution estimating the ‘cost of harm’ in 2022/23 alone to be £4 billion – £126 per second. But greater still is the human cost, with lives forever altered by preventable harm.
Behind these statistics lie harrowing tales of distress and disillusionment. A quarter of respondents to the recent CQC maternity survey expressed feeling unheard during labour and birth and in 2022, 63% of midwives reported experiencing stress-related illnesses in the past year. These narratives underscore systemic issues encompassing culture, leadership, inequality, and accountability that continue to thwart efforts to deliver safe maternity care.
Where are we going wrong?
A review of maternity initiatives in the English NHS covering 2010–2023 concluded that ‘poor transparency of reporting and weak or absent evaluation’ were undermining improvement effort’. The research identified ‘…widespread poor practice in programme design, transparency of reporting and evaluation’, so part of the problem is that we lack a detailed understanding of what has been working well, what hasn’t and why.
At a national and local level, gaps exist between recommendations to learn from patient safety problems and the changes intended being implemented. At a national-level, inquiries are carried out but too often the inquiry chair and panel are then quickly disbanded with their recommendations sitting loosely in the system with no rigorous oversight or accountability for implementation. A recent report from the expert panel of the Health and Social Care Select Committee (HSCS) looked at five recommendations from independent inquiries and reviews going back to 2013, covering recommendations to improve maternity care and leadership, staff training, safety culture, and whistleblowing. The report found ‘concerning’ delays to take real action to implement recommendations and rated the overall progress by the government as “requiring improvement.”
A lack of courage to confront difficult issues
The issues holding back maternity safety improvement are complex and some have become toxic and difficult to raise. Strong evidence points to decades of advocacy for “normal birth” having inadvertently led to a culture that devalues medical intervention and pulls against the approach needed for safe maternity care. Interprofessional tribalism further exacerbates tensions, hindering collaboration and trust between midwives, obstetricians and other maternity professionals. Moreover, there remains a culture of fear – a lack of ‘psychological safety’ for staff and a leadership culture that prioritises reputation over patient safety, perpetuating a cycle of secrecy and denial.
Whist non-confrontational issues relating to workforce and the need for more investment are frequently (and rightly) championed, there appears to be a reluctance to acknowledge these other more difficult problems explicitly, and an unwillingness to examine the causes and develop strategies for improvement. For example, the Maternity and Newborn Safety Investigations (MNSI) programme (formally part of HSIB) have been conducting independent investigations into certain maternity safety incidents since 2018. MNSI do not dispute that their investigations ‘regularly pick up’ a ‘professional bias towards the normalisation of pregnancy and childbirth’ as a factor in what happened, yet no mention of this has been published and the issue is absent from any thematic work intended to inform national learning and change.
Where can we go from here?
The recurrent call for national inquiries underscores the systemic and persistent nature of the challenge. Addressing fundamental issues demands a holistic approach that transcends individual unit-level investigations. This entails reimagining the entire maternity system, from education and training to regulatory frameworks and cultural norms. At its core, this is a call for systemic transformation—a recognition that the current system is failing not only women and families but also the dedicated staff on the front line. It is a call to confront uncomfortable truths, dismantle entrenched barriers, and forge a path toward a future where every mother and baby receives the safe, dignified care they deserve. Where all maternity services are safe not just for the ‘majority’ – ‘most of the time’, but for ‘everyone’ – ‘all of the time’.
Recently conversations with senior system leaders suggest to me that there is currently great resistance to deviating from the current path; a fear that the landscape is already too complex and that ‘…we need to get on with the changes that we know are needed rather than start another inquiry that will cause delays and add to the complexity’. This is the wrong approach.
In my view we do need a fresh national review of maternity safety. This wouldn’t need to delay work already in motion, rather it could run alongside and consider the impact of what is already in progress. Crucially, a new national review could evaluate the work that has been undertaken to date, build on what has worked, identify the gaps and make badly needed recommendations to improve and streamline the national infrastructure and support to drive improvement – in much the same way as the national plan to improve cancer care did in 2000. It can be done.
James Titcombe – April 2024
patientsafetyfirst 