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that all women should receive information about GBS, the use of Enriched Culture Medium (ECM) where testing was recommended and identified women who should be offered antibiotics during labour. However, a recent report found 20% of Trusts had not updated their local guidelines since 2017 and the majority were using the wrong swab and lab methods for testing for GBS. The Minister of State for Patient Safety,
Suicide Prevention and Mental Health, told the Committee that she was aware of these shortcomings and that she had written to the CEOs of all Trusts on the matter making clear that Trusts “ensure that they are using the ECM testing as of the moment they receive the letter”.
Pursuit of normal childbirth ‘at any cost’ The report of the Morecambe Bay investigation described the “pursuit of normal childbirth ‘at any cost’”. The Committee pointed out that similar themes have emerged from the interim Ockenden report into Shrewsbury and Telford. Giving evidence to the Committee, Donna Ockenden said that the review had:
“Spoken to hundreds of women who said that they felt pressured to have a normal birth […] at that Trust, there was a multi- professional, not midwife-led, focus on normal birth pretty much at any cost.” Expert witnesses told the Committee that these badly failing units should not be taken as an indication that such problems are widespread. However, the Committee heard from Clotilde Rebecca Abe that a mum she supported was made to feel like a failure by her midwife, because she opted for a Caesarean section. The report points out that such anecdotal evidence suggests that, in some cases, there is still clinician-led pressure for women to choose vaginal delivery, even when this may not be in their best interests.
The Committee called for organisations to “stamp out the damaging ideological focus on ‘normality at any costs’, which caused such huge loss and suffering at Morecambe Bay and Shrewsbury and Telford.”
Personalised care The Committee’s Expert Panel also rated the Government’s progress towards providing personalised care as ‘inadequate’ and stated that “personalisation must go hand-in-hand with safety”. Women must be fully and impartially informed about the safety risks associated with all birthing options and be provided with clear information about the likelihood of interventions.
The Committee also added that timely and appropriate pain relief is also an essential part of safe and personalised care. It emphasised that every woman giving
birth in England should have a right to their choice of pain relief during birth, in line with clinical advice on what would be safest for them and their baby.
It called for NHS England and Improvement to establish a working group comprising of women and their families, organisations providing support for women throughout their pregnancy and clinicians to develop a set of actions for maternity services to consider in order to ensure no woman feels pressured to have a vaginal delivery and is always informed clearly what the safest option is for her birth. The working group’s remit should also include researching and addressing the wider societal factors, including media and social media, that put pressure on women to want to have an unassisted birth. Other recommendations put forward by the Committee included an immediate end to the use of total Caesarean Section percentages as a metric for maternity services. Commenting on the report, Health and Social Care Committee chair, the Rt Hon Jeremy Hunt, said: “Although the majority of NHS births are totally safe, failings in maternity services can have a devastating outcome for the families involved. Despite a number of high-profile incidents, improvements in maternity safety are still not happening quickly enough. “Although the NHS deserves credit for reducing baby deaths and stillbirths significantly, around 1,000 more babies would live every year if our maternity services were as safe as Sweden. “Our biggest concerns were around staffing and culture: staffing levels have now started to improve but we found a persisting ‘culture of blame’ when things go wrong which not only prevents people admitting that mistakes were made, but crucially, prevents anyone learning from them. “Our independent expert panel gave an overall verdict of ‘requires improvement’ which sends a strong message that the Government and the NHS need to redouble their efforts ahead of the Ockenden report into
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Shrewsbury and Telford and the Kirkup report into East Kent. Nothing less is owed to the families for whom a birth was not the joyous occasion they had the right to expect.” Professor Dame Jane Dacre, chair of the Health and Social Care Committee’s Expert Panel, added: “This is the first evaluation of its kind, commissioned by the Health and Social Care Committee and carried out independently by a panel of experts. Using a CQC-style scoring system, we have rated the Government’s overall progress on its maternity services’ targets as ‘requires improvement’. “Our Expert Panel report covers in greater detail how far the Government’s maternity commitments have been achieved in key areas. Three commitments have been rated as ‘requires improvement’ – maternity safety, continuity of carer, and safe staffing – while a rating of ‘inadequate’ has been given to the commitment to provide all women with a personalised care and support plan. “We’ve also found persistent health inequalities experienced by women and babies from disadvantaged groups, with poorer outcomes across all of the commitments we considered. However, underpinning all this are workforce issues. Maternity services must have the right number of staff, in the right place, at the right time and with the right skills – without that, progress will stall.”
References 1 Kirkup, B, Morecombe Bay Investigation report, March 2015, accessed at:
https://www.gov. uk/government/publications/morecambe-bay- investigation-report
2 Ockenden, D, Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust, December 2020, accessed at: https://assets.
publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/943011/ Independent_review_of_maternity_services_at_ Shrewsbury_and_Telford_Hospital_NHS_Trust.pdf
3 Lintern, S, ‘East Kent maternity inquiry to examine failings spanning more than a decade’, The Independent, 12 March 2021, accessed at:
https://www.independent.co.uk/news/health/east- kent-hospitals-university-trust-maternity-baby-
death-b1815925.html
4 Accessed at:
https://iiekms.org.uk/about-the- investigation/
5 East Kent Hospitals University NHS Foundation Trust HSIB summary report, April 2020, accessed at:
https://www.gov.uk/government/publications/east- kent-hospitals-maternity-services-hsib-summary- report
6 First Special Report - The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of maternity services in England, July 2021
7 The safety of maternity services in England, The Health and Social Care Committee, July 2021
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