Recommendations of UK Maternity Review are an insult to the memories of those who died


Why didn’t they just spit on their graves?

That would hardly be more disrespectful to the dead than the mind boggling recommendations released by the supposedly comprehensive Review of Maternity Services. After reviewing the dozens of preventable infant and maternal deaths, nearly all due to LACK of supervision of midwives and LACK of technological interventions, the Review recommended … wait for it … LESS supervision of midwives and LESS access to interventions!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Have these people lost their minds? No, they’re simply playing politics.[/pullquote]

That’s right. Although the Review found babies and mothers died from the same causes over and over again: failure of midwives to appropriately classify the risk level of patients, failure of midwives to use lifesaving technology, failure of midwives to call doctors who could save babies and mothers, the main recommendation is:

All pregnant women will be provided with maternity budgets of £3,000 to pay for personal midwives and home births.

Despite the fact that dozens of perinatal and maternal deaths occurred because midwives refused to consult doctors and withheld lifesaving treatment, the UK government apparently thinks the solution is less supervision for midwives, and less access to lifesaving treatment.

Have these people lost their minds? No, they’re simply playing politics, kowtowing to the powerful midwives union (the Royal College of Midwives) and pandering to those who are looking to save money on maternity care regardless of who dies as a result.

The impetus for the Review was the Morecambe Bay report investigating a Cumbrian midwife-led hospital unit after a series of preventable perinatal and maternal deaths The report identified 16 perinatal deaths and 3 maternal deaths that had taken place in the unit as potentially preventable. The cause?

…[M]idwives took over the risk assessment process without in many cases discussing intended care with obstetricians, and we found repeated instances of women inappropriately classified as being at low risk and managed incorrectly. We also heard distressing accounts of middle-grade obstetricians being strongly discouraged from intervening (or even assessing patients) when it was clear that problems had developed in labour that required obstetric care. We heard that some midwives would “keep other people away, ‘well, we don’t need to tell the doctors, we don’t need to tell our colleagues, we don’t need to tell anybody else that this woman is in the unit, because she’s normal’”

Unfortunately, Morecambe Bay was not an isolated incident. At Royal Oldham/Greater Manchester, seven babies and three mothers died in just eight months. And at Milton Keynes:

History is repeating itself with the deaths of FIVE more newborn babies following staff failures at the hospital maternity unit…

Milton Keynes has now seen at least eight such deaths in two separate periods over the last eight years.
The latest five deaths happened over eight months between 2013 and 2014…

Most of the deaths involved staff failing to recognise or act upon warning signs of foetal distress.
All the babies were full term and previously healthy, and in each case parents claim speedier medical intervention could have saved their lives.

The Maternity Review confirmed that there is an epidemic of preventable perinatal and maternal deaths in the UK maternity care system:

Half of hospital maternity units are failing to meet basic safety standards, according to the NHS watchdog.

A total of 7 per cent have been rated ‘inadequate’ and a further 41 per cent ‘require improvement’.

NHS experts warned that at the worst units there are ‘dysfunctional relationships’ between midwives and doctors who are working in ‘silos’ – almost independently of one another.

The number of mistakes is simply appalling:

At least 340 blunders are occurring on NHS maternity wards every day, figures reveal.

Mothers and babies are routinely being harmed as a result of mistakes by midwives, doctors and other staff.

Although most errors are classed as ‘near misses’ or low injury, some have tragic consequences. Last year, 151 women and newborns died on maternity wards and another 351 suffered severe harm.

How would providing women with money enabling them to choose midwife led units and homebirths address these deadly mistakes? It wouldn’t and it couldn’t:

If the problem is a midwifery philosophy that privileges unmedicated vaginal birth above the lives of babies and mothers, allowing midwives more scope to excercise their personal philosophy is likely to lead to MORE mistakes and MORE deaths.

If the problem is that midwives fail to collaborate and consult with doctors, allowing more midwives to practice where doctors aren’t available is likely to lead to MORE mistakes and MORE deaths.

If the problem is that midwives are failing to use lifesaving interventions, promoting homebirth where midwives could not possibly be farther away from life saving interventions is likely to lead to MORE mistakes and MORE deaths.

No matter. The recommendations of the Review are divorced from the reality of the findings because the maternity allowance was a done deal, decided upon long before the evidence was even examined.

UK patient advocate James Titcombe, father of baby Joshua who died at Morecambe Bay specifically because midwives refuse to consult a pediatrician, was one of the original members of the Maternity Review panel. He resigned shortly after the early meetings.

I’m concerned that the review isn’t following an evidence based approach. The work looking at evidence about the current qualitify and variation in safety is only just starting (it was only instigated at all as an afterthought). Robust evidence … should surely form the starting point …

I felt that the balance of the maternity review is weighted towards the professional voice. Those who have suffered avoidable harm of loss … are not in my view properly represented and are not being heard as clearly as they should…

Sadly, the Review was a piece of political legerdemain, pretending to address the issue of safety, but actually used to promote the goals of the midwifery trade union and provide cover for efforts to cut maternity costs by forcing women out of hospitals and into homebirth.

The end result? Babies and mothers will continue to die preventable deaths in the UK maternity system because politicians are more concerned about politics than about babies lives.

The recommendations of the Maternity Review are an insult to the memories of those who died preventable deaths at the hands of the maternity system, but apparently the Review was never meant to improve maternity care.