Mothers suffering ‘shockingly poor quality’ of maternity care, says birth trauma report
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Birth trauma caused by mistakes and failures was “frequently covered up by hospitals”, a landmark report has found.
The first parliamentary inquiry into birth trauma heard “harrowing” evidence from more than 1,300 women and found that good care was “the exception rather than the rule”.
Women told the inquiry how hospitals caring for them during labour had tried to cover up medical negligence that had left either themselves or their children with life-changing injuries, including in one instance removing a healthy bladder.
The report, published on Monday, calls for an overhaul of maternity and postnatal care as mothers revealed their children had suffered life-changing injuries due to medical negligence, while others had been left in blood-soaked sheets after giving birth.
One woman was dismissed as being an “anxious mother” by staff before her baby died of the complications she had been concerned about.
The birth trauma inquiry was set up by Theo Clarke, Conservative MP, who thought she was going to die when she gave birth to her daughter Arabella in 2022.
The report made 12 recommendations, including the creation of a new maternity commissioner who would report directly to the prime minister.
Amanda Pritchard, the NHS chief executive, said the experiences of women outlined in the report were “simply not good enough”.
The NHS and the Government have committed to a maternity services strategy in the wake of the report, which found widespread failures and a cover-up culture by hospitals that “frustrated parents’ efforts to find answers”.
The number of women who die during pregnancy or shortly after has risen to a 20-year high at 13.41 deaths per 100,000 pregnancies between 2020 and 2022, according to figures published by the MBRRACE-UK investigation into maternal deaths in the UK. The figure was 8.79 in the period 2017 to 2019.
There were 605,479 live births in England and Wales in 2022, down by 3 per cent on the year before.
It is estimated that 30,000 women a year, in the UK alone, have suffered negative experiences during the delivery of their babies while one-in-20 develops post-traumatic stress disorder (PTSD).
‘Postcode lottery’ of maternity care
Ms Clarke said there was “a postcode lottery” for maternity care in this country.
“I don’t think it is acceptable – that depending on where you live, you will literally be offered a different level of care in terms of how you’re given support during childbirth and afterwards,” she told the BBC’s Today programme.
She recalled her own experiences of giving birth and said: “I remember pressing the emergency button after I’d come out of surgery and a lady came in and said she couldn’t help me, said it wasn’t her baby, wasn’t her problem and walked out and left me there.
“So we need to make sure there are safe levels of staffing.”
The report comes after investigations into Shrewsbury and Telford Hospital NHS Trust, where failures had contributed to the deaths of 201 babies and nine mothers over 20 years, as well as scandals at Morecambe Bay and East Kent.
Donna Ockenden, who led the Shrewsbury inquiry and is currently carrying out the largest maternity review in the UK at Nottingham University Hospitals NHS Trust, said the report “highlights the extent of the problem we know exists across maternity services in the UK”.
She said she had given the Government a “clear blueprint and roadmap” for maternity services but “progress has been far too slow”.
One mother, called Helen, told the report of her mental and physical pain a year after giving birth to her son, Julian, who was born with a hypoxic brain inquiry because of negligence.
“My life will never be as it should be,” she told the inquiry. “I never returned to work, I live a very secluded life, as friends and family shun you when you have a disabled child that they might not understand or are scared of.”
Another said she had her healthy bladder removed during an emergency caesarean section and was wrongly told that the placenta percreta had enveloped the bladder and that she would have lost it anyway. A urologist blew the whistle on the cover-up.
One woman told the inquiry: “I was concerned that my baby was looking ‘yellow’ and asked the midwife. She told me I was being overly anxious and he was fine. She wrote in my notes that I was an overly anxious mother and my baby was not jaundiced. My husband intervened and a doctor confirmed my baby was jaundiced and he was treated. The next day the page written by the midwife had been torn out.”
The report said: “In many of these cases, the trauma was caused by mistakes and failures made before and during labour. Frequently, these errors were covered up by hospitals who frustrated parents’ efforts to find answers.”
It added that there should be a “base standard in maternity services”, an end to the postcode lottery of perinatal care, and mothers should be given “universal access to specialist maternal mental health services across the UK”.
It urged the Government to outline how it would “recruit, train and retain more midwives, obstetricians and anaesthetists to ensure safe levels of staffing in maternity services and provide mandatory training on trauma-informed care”.
Another key suggestion was to “provide support for fathers and ensure [a] nominated birth partner is continuously informed and updated during labour and post-delivery”.
Twelve recommendations
The report from the All-Party Parliamentary Group on Birth Trauma included 12 recommendations in total, including a plea for mothers’ health records to be digitised.
Victoria Atkins, the health secretary, said the findings were “harrowing” and that she was determined to improve care.
In January, she shared her personal experience of the “darker corners” of the NHS after giving birth as a patient with Type 1 diabetes.
“I am determined to improve the quality and consistency of care for women throughout pregnancy, birth and the critical months that follow, and I fully support work to develop a comprehensive national strategy to improve our maternity services,” she said on Monday.
She added: “We are now investing £186 million a year more than in 2021 to improve maternity and neonatal care, and we announced an extra £35 million at the Spring Budget to boost maternity safety, with more midwives and better training.”
The NHS said it was working with leaders at all trusts with maternity and neonatal services in England on a national programme to create a culture where women are listened to and care is safe.
Ms Pritchard said: “We know there is more that can be done to prevent and improve support for birth trauma, which is why we are committed to working with the Department for Health and Social Care on a cross-government strategy to build on the NHS three-year delivery plan for maternity and neonatal services, so that we can continue to make care safer and more personalised for women and babies.”
It comes two years after a report into service failings at East Kent by Dr Bill Kirkup revealed a culture of “deflection and denial” among staff, “the effect of these behaviours was to cover up the truth”.
