What’s gone wrong with maternity, and how can it be put right? That’s the question many NHS managers and boards will be asking after a series of maternity service scandals and two damning reports delivered earlier this summer.

In one sense, what’s gone wrong is now clear. In multiple inquiries, from Morecambe Bay in 2015 to Nottingham University Hospitals this summer, similar themes have been laid bare.

Poor inter-professional working, a failure to listen to mothers and families, a lack of compassion, boards unaware of what was happening on the ground, and a push for women to have ‘normal’ births beyond the point at which intervention was needed are all common failings identified in successive reports.

But behind those are deeper questions about the working culture in maternity services and how to change it, how trust boards can understand the issues and act accordingly, and about the role of regulation and how it can aid improvement.

Despite this, many NHS trusts see the recommendations as largely about other trusts. Until the Amos maternity and neonatal ‘rapid review’ reported this summer, previous maternity investigations concerned a particular trust and its failings. While all trusts were expected to implement some recommendations, for most, their services were not under scrutiny. “When I look back ten years, it was Morecambe Bay this and Morecambe Bay that,” says one manager with extensive experience in maternity. “But the issues are systemic. They are not limited to one trust.”

There is also a question mark over where maternity services sit within trusts. A Health Services Safety Investigation Branch (HSSIB) exploratory review into maternity last year said: “We heard that often maternity services are ‘disgruntled’ and not treated as part of a trust, but also that maternity services do not wish to be treated as part of trust services.“

Bill Kirkup, who authored reports on maternity services at Morecambe Bay and East Kent University Hospitals, agrees maternity is treated a little differently. “That’s probably not from managers but I think it’s from fellow clinicians,” he says. “The nearest example may be psychiatry [which] is regarded as different and dealing with a different client group, and staffed by people who are different.”

Clinicians know how rapidly a pregnant woman’s condition can change and escalate into something serious requiring urgent attention, he says. When a maternity patient is admitted to a surgical or medical bed elsewhere in the hospital, staff “can’t wait to get her off the ward. Other clinicians have lost touch [with] and any interest in maternity, and they don’t really feel a kinship with it.”

Maternity is also unusual in having two professions—midwifery and obstetrics—taking the lead, leading to sometimes confused lines of accountability. Midwifery has traditionally been overseen by the chief nursing officer, who is unlikely to have midwifery experience and, until recently, most trusts didn’t have a director of midwifery. Similarly, many chief medical officers will have limited experience of obstetrics.

Maternity does need to work closely with other services, says Dr Jenny Barber, vice president for clinical quality at the Royal College of Obstetricians and Gynaecologists, and good care is dependent on communications and collaboration across departments.  

But in some cases this isn’t happening. In her report on Nottingham’s maternity services, Donna Ockenden highlighted that anaesthetic governance sits outside the maternity governance framework—despite the key role anaesthetists have in many births. This meant, for example, that anaesthetists were not informed about the outcomes of rapid reviews of adverse events, potentially limiting their learning.  

Maternity units are also dealing with a rapidly changing clientele: more older mothers and more women with pre-existing health conditions, who are likely to need more care during birth and beyond. “What does this mean in terms of staff, length of stay, bed numbers? How is this big shift being understood in terms of service capacity?” asks Sarah Scobie, deputy director of research at the Nuffield Trust.

In 1970, Caesareans accounted for only 4% of births, rising to around 20% by the early 2000s. Today, the Caesarean rate—elective and emergency—is 46%, and only 43% of pregnant women give birth vaginally without the use of instruments.

Barber points to the rising workloads, staffing gaps and the estates, theatre and equipment issues which plague many maternity departments. The government needs to fully fund the national action plan—prompted by the Amos review—which is expected around Christmas, she says. But there will also be a challenge for boards.  

“The demands on their maternity services are changing, and boards and NHS managers need to ensure they have the right number and mix of multidisciplinary staff, and understand rota gaps across the multidisciplinary team, training capacity, educational supervision and succession planning,” she adds.

NHS leaders should also use more local data to understand the needs of their local populations and how it impacts on maternity service demand, she says.

It would be very hard now for a board to claim it was not kept informed about its maternity service. In a noticeable change in recent years, most boards now regularly review data and qualitative reports on maternity services, which often run into dozens of pages. They are also required to sign off on submissions to NHS Resolution for the maternity clinical negligence scheme. Rebates on this—which depend on meeting certain quality measures—can be worth seven figure sums to some trusts.

But is this plethora of information making much difference? Arguably, boards at some of the 12 trusts examined by Baroness Amos had access to plenty of information but had not publicly acknowledged—or possibly realised—there were serious failings in their services. It was often pressure from bereaved parents or highly critical CQC inspection reports which ‘revealed’ their problems.

One NHS manager with experience of maternity is doubtful that the level of data boards are seeing is actually helpful. Boards may need more distilled information, they suggest. And meeting so many recommendations can lead to service improvement becoming a tick-box process.

Kirkup, who was a trust non-executive director for a time, says: “I can remember being confronted with pages and pages filled with a gigantic chequerboard of green, amber, red and blue points… they are just impossible to interpret.” Boards need clear data showing what the problems are and what is causing them, he adds.

This has started to happen with the maternity outcomes signal system (MOSS), which was developed by NHS England in response to the East Kent Hospitals review and went live last year. Trusts now get warnings when certain indicators rise above what would be expected. It is, of course, up to them whether anything happens in response, or whether adverse signals are ‘explained away’.  

Unfortunately, there’s plenty of evidence that trusts have taken little action when given information about problems with maternity services in the past. Kirkup—who called for the development of MOSS in his report on East Kent and supports the initiative—says: “I think it’s lack of attention. We saw that in East Kent, where things were going wrong for a prolonged period of time but they did not know what to do.

“I think that is partly a product of ‘we don’t quite understand this unit.’ If that happened in a surgical unit that would have been different,” he adds.

Boards are coming under pressure to increase scrutiny, with NHS England chief executive Sir Jim Mackey recently sending trusts a list of ten demands, including improved triage, joint board-level accountability between chief medical and chief nursing officers for maternity and neonatal care, and 24/7 responsiveness with safe service arrangements.

But many managers already feel overwhelmed with new demands and recommendations, an issue highlighted in the Amos review. “We consistently heard from senior leaders in trusts that the number of recommendations directed at maternity and neonatal services [is] overwhelming and take time to implement,” it said.

The HSSIB report also highlighted the complex national infrastructure around maternity and neonatal care, and the large number of recommendations in recent years, many of which have seen only limited implementation.

And, while NHS England’s ten-point plan has been welcomed by some, it was immediately followed by the requirement to report on 25 maternity “asks” by the end of September and again in December. 

Some doubt the recent plethora of recommendations will do much to change the culture in maternity services, especially persistent reports of race discrimination and a lack of compassion. “We have not done much about underlying problems… we are looking at what happens at the surface. It is not the answer. It will come back again“, warns Kirkup.

Managers face a challenge in understanding the cultures and sub-cultures within departments, he explains: “If you are working in a system which has all sorts of informal hierarchies just putting something in at the top and trying to instil a different culture won’t work.”

One of the most shocking revelations in recent reports has been the practice of giving junior or inexperienced midwives difficult deliveries as a challenge. 

“That’s a thing that someone sitting in a CEO’s office is not going to be able to detect very easily,” Kirkup says. “Finding out what’s happening is going to need a wider process as no one is going to confess to behaving like this.

“If you are having just a single interview with people you are not going to find it out,” he adds. “You need to go back and talk repeatedly to people and this is difficult with the way the NHS is operating,” he says.

Changing culture is “a massive task, not just in maternity,” one manager told me. “But fundamentally it’s all about accountability. Maternity can seem pretty unmanageable but if you have the right structure in place, it is manageable.”

But, in the face of what can feel like unrelenting criticism, maternity also needs to be an enjoyable place to work, they add. “I think on the whole it is, with lots and lots of positives.”

Trying to change a culture where staff have become accustomed to working in a certain way, can be extremely hard, Kirkup warns, and a “hero leader” trying to make rapid changes may not be helpful and is unlikely to be sustainable. Nor are top down pronouncements – this sort of change needs to happen at the “sharp end”, he says.

It’s a big challenge for managers, says independent consultant and former Nuffield Trust chief executive Nigel Edwards, as they must be willing to tackle some of the tough cultural issues, and what he describes as the “normalisation of deviance”. Managers need to acknowledge these problems are systemic and don’t just affect particular trusts, and ask whether they are complicit in the institutional resistance to accepting this, he explains.

But Edwards also questions whether general managers have the skills and knowledge to lead maternity services. “General management is an important skill, but if you’re managing a complex clinical area you do need specialist skills,” he says. “It’s not enough to be a good manager, you do actually need to know something about what you are managing. You need to have the knowledge of what good looks like.”

Ockenden’s Nottingham report noted that the trust’s chief executive took direct control of a maternity improvement plan in 2019, but the “feedback from senior stakeholders is that they did not have the expertise, experience or knowledge to effect the changes required”.

But perhaps the most worrying question is whether these failings are unique to maternity services – there have been similar issues in other areas such as cardiac surgery, Edwards points out. Maternity failings could be more prominent because of the very high costs involved in cases which progress to clinical negligence claims, but other services can also feel distant from the main flow of a hospital and involve clinicians whose work is not easily understood by others. “Why do you think it is only maternity?” he asks. //