Had she lived, Kate Stanton-Davies would have just turned 13. She should have been a teenager with her whole life before her, yet as it was she survived for only six short hours. The legacy of that brief time is a harrowing report published this week into the failure of maternity services at the Shrewsbury and Telford hospital trust, where her mother, Rhiannon, gave birth to her.
The senior midwife leading the inquiry, Donna Ockenden, said that after talking to some of the hundreds of bereaved families who gave evidence she would sometimes go home and cry. I did too on reading the report, which concludes that no fewer than 201 babies and nine new mothers who died over a period stretching back to the millennium could or would have lived with better care.
The stories are haunting. Take the unnamed mother worried about delivering vaginally after a previous caesarean birth, a process that can risk ripping open the old scar, who was pressed into doing so and died on the operating table. Or Kayleigh Griffiths, who had a home birth, and phoned the midwifery service repeatedly overnight with worries about her daughter Pippa’s feeding, breathing and other symptoms; her baby died the next morning of neonatal meningitis, and an inquest later ruled she could have survived with better care.
And then there is Rhiannon Davies, whose baby Kate stopped moving in the last weeks of pregnancy – a clear indication of problems – but who was still deemed low risk and sent to a midwife-led unit not equipped to deal with what turned out to be a very sick baby.
It’s thanks to Kate’s and Pippa’s parents, who persuaded the then health secretary Jeremy Hunt to open an inquiry, that we now know not only these stories but countless more: babies born brain-damaged who needn’t have been; the survivor of sexual abuse whose baby lived but was so traumatised by her experience on the labour ward that she barely left the house for four years; the woman who suffered a fourth degree tear – and if you don’t know what that is, then trust me you don’t want to – after a junior doctor made a basic error during a forceps delivery, which did not appear even to have been raised with that doctor as a training issue to ensure it didn’t happen again. Since the trust “failed to investigate, failed to learn and failed to improve”, in Ockenden’s words, the same mistakes happened over and over again.
And sadly, that’s not unique. Similar stories emerged from a 2015 inquiry into maternity services at Furness general hospital in Morecambe Bay, while new inquiries into maternity services in Nottingham and East Kent are currently under way. Why, in an era of miraculous medical advances, are we still so bad at ensuring women can give birth safely, easily and without going home traumatised?
For nowhere else in hospitals are people expected to be proud of their “natural” ability to endure pain without relief. Only childbirth still involves endless guilt for mothers about doing it “right”, combined with techniques of almost medieval barbarism; dragging stuck babies out by their heads with forceps, and patching up their mothers’ ripped flesh afterwards with a shrug. (I’m sorry if this is gory to read, but it’s much more gory to go through.) It’s estimated up to 28,000 women a year in the UK emerge from childbirth suffering from post-traumatic stress disorder, a condition more often associated with soldiers at war or survivors of violent crime.
If patients were emerging in this state from any other routine procedure we’d be demanding to know what had gone wrong, and surely many of these traumatising experiences must involve near-misses from which life-saving lessons could be learned. Yet women are expected to accept that staggering out of the labour ward feeling as if you’ve been in a car crash is somehow normal; after all, doesn’t half your National Childbirth Trust group feel the same? There is intense pressure not to complain publicly for all sorts of reasons, ranging from embarrassment about discussing the grisly state of your innards or reluctance to frighten pregnant friends to the fear of seeming ungrateful merely to have survived. If you got to take home a healthy baby, it can feel selfish to complain. The idea that motherhood means sacrifice, or burying your own feelings, runs deep and on some labour wards seems actively encouraged.
One woman whose baby had been whisked off to the neonatal unit for treatment told the Ockenden review she had been scolded for complaining of postpartum pain; midwives apparently told her that “women who have babies next to them have more important things to think about. People like you, who do not, are only concerned with themselves.” Another was called “a princess” for asking for formula feed for the baby. Wanting a caesarean, a perfectly rational response to a previous traumatic delivery or even to fear of what may happen on understaffed and overstretched wards, is still widely mocked as being “too posh to push”, a misogynistic moral judgment that would sound ridiculous applied in any other field of medicine.
Ideological resistance to C-sections was clearly part of the story in Shrewsbury and Telford, where the trust prided itself on a startlingly low caesarean rate while seemingly sweeping the consequences under the carpet. Ockenden concluded this approach was harmful for some and welcomed new NHS England advice not to judge hospitals on their caesarean rates, reversing years of pressure for more “natural” births (which also just happen to be cheap). But the report is clear that isn’t the whole story. Similarly, while it backed recent calls for a £350m annual increase in England’s cash-starved maternity budget now, lack of money doesn’t explain avoidable deaths in Shropshire dating back to the 2000s, relative boom years for NHS funding.
What stands out from her report is something much harder to change: a culture of overconfidence and resistance to scrutiny inside a service one interviewee dubbed the “Republic of Maternity”, alongside a bullying culture among midwives which left staff afraid of ridicule if they asked for help. Mistakes were inevitably made, and grieving families fobbed off or ignored.
What Ockenden is describing is a familiar mixture of arrogance, fear and denial which won’t end until professionals are properly supported in admitting near misses – the lesson of virtually every patient safety report ever commissioned – and women who have endured horrific labours feel encouraged to talk about them. There is no “right” way to give birth, no perfect model that mothers should beat themselves up for not attaining. But there are some tragically very wrong ones, and many of them start with refusing to listen to women.
Gaby Hinsliff is a Guardian columnist
