Giving birth in England is considered very safe. But it doesn’t mean we can’t do more, and it doesn’t mean we should only look at mortality. There are other questions we need to be asking: What kind of start are we giving mothers? Do they feel safe giving birth? Do they feel safe in pregnancy? Do they feel safe in those first few weeks and months looking after that tiny new person?
Motherhood is hard. Looking after mothers so that they can take good care of their babies makes good sense, so maybe looking after those who are caring for mothers makes good sense too?
The Royal College of Midwives (the UK’s only midwifery union) predicts that there is a shortfall of over 2000 midwives in England  and yet a recent survey of its members revealed that 57% are considering leaving the profession in the next year. As a student midwife, it is disheartening entering a profession where morale is so low, and I wonder what effect this has on safety?
All jobs have their downsides and midwifery is no exception. But if changing these downsides meant safer better births, is that not worth the cost? No more missed breaks. No more reduced breaks. No more finishing late without being reimbursed. No more midwives with UTIs because there simply hasn’t been time to stay hydrated and use the bathroom. No more signs up about staff room valuables being stolen because everyone would have a locker. No more ‘pay rises’ that are effectively pay cuts. No more buying extra uniforms because not enough have been provided to comply with infection control policies. No more fishing a teabag out with the end of a knife. Maybe that last one sounds silly? But I do think the small things count. The small things that can help staff feel cared for whilst they put their emotional and physical energy into keeping mums and babies safe.
Caring for a new baby is an amazing time for many parents, but it’s no walk in the park. Often friends and family members want to make it easier for the parents, but they don’t know how to. There’s a bit of a cliché that if we look after the mum, we’ll look after the baby. I wonder if it is the same in midwifery? If we look after the midwives, we look after the mums.
If we imagine a hypothetical scenario where somebody’s life is in danger and the doctor says we can save you, we just need to do ‘x’. Most people will do whatever ‘x’ is to save their life – it is a very basic survival instinct. However, real life scenarios are rarely this straightforward; in real life, the risks are not always so clear cut, sometimes we have good evidence of the mathematical risk of doing (or not doing) something, and at other times we don’t know. The other problem with real life scenarios is dealing with real people, each with their individual needs, values and lifestyles.
So in real life, the issue of safety is also more complicated than survival. Safety in maternity services is not just about keeping mum and baby alive. It is absolutely a worthy goal to improve perinatal mortality rates, I am not sure anyone would argue with that, but this should be our base level for safe care. And what comes on top of it is not just a bonus, it is actually very important and can have a huge impact on future health and wellbeing.
So what are a few of the key safety issues? We can’t think about safety in maternity without considering some of the alarming disparities highlighted in the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) report. It showed that black and Asian women have a higher risk of dying during pregnancy and that those who live in the most deprived areas are also more at risk of death in pregnancy and the period after.
We can’t consider safety in maternity and ignore the recent Ockenden report, which highlighted major failings at one particular trust, but with wider implications. Like previous investigations into maternity service failings, one key issue is workplace culture. The kind of culture where staff live in fear of speaking up when things are going wrong, the kind of culture where staff don’t want to go into work anymore.
We have maternity services with a one size fits all approach, where a lot of midwives are leaving and staffing is already short, where disparities in outcomes because of race exist, all set in a culture where fear and blame are rife.
How did we get to this? I can’t imagine any midwife sets out to become a part of the problem. But how can you give individualised care when you are just keeping your head above water? How can you stay in a job that leaves you exhausted because you are covering the shortfall?
Tackling disparities requires time to train staff to become culturally competent and plan care that is personalised and non-judgmental. As midwives and student midwives, safe care includes appreciating the nuances of each client we work with. Appreciating the nuances of each team member so that effective teamwork changes the culture and it is a joy to go to work every day.
So many of these changes start with individuals. Individual midwives. Individual student midwives. Individual obstetricians. What if we looked after these staff members? What if we gave them the same great care and respect we expect them to provide? This is not a negative woe-is-me kind of blog. This is a dreaming blog - this could happen! There could be more care and compassion for the maternity workforce. And what kind of difference could it make?
With recent railway strikes, there are whispers of union action in other public services. This issue feels more complicated in caring professions like midwifery. Balancing the legal right to strike with the legal responsibility to care for childbearing women. I have never met a midwife whose primary reason for choosing the career was to make money. It is a job of passion, love and dedication. But this does not mean it should be poorly paid with poor conditions. Quite the opposite in fact.
Midwifery is sometimes seen as a profession primarily relating to women, and this is true. But actually, midwifery affects everyone: partners, children, whole families, future generations. Midwives are involved in virtually every pregnancy, and almost every birth is attended by a midwife. Everybody is born. What kind of working conditions would you have wanted for the midwife caring for you at your own birth? And what kind of working conditions will midwives have as they serve future generations? Because you can bet your life it will impact the quality of care they can offer.
1 Falling NHS midwife numbers show worrying trend says the RCM. Royal College of Midwives, 18 May 2022
2 RCM warns of midwife exodus as maternity staffing crisis grows. Royal College of Midwives, 4 October 2021
3 Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), November 2021
4 Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust. 30 March 2022