" 'over-zealous' pursuit of natural childbirth ‘at any cost’ led at times to unsafe care " and deaths in Morecambe Bay maternity unit

[inamaymaybewrong]

Thoughts on this, which is getting a lot of coverage today?

www.gov.uk/government/news/morecambe-bay-investigation-report-published

Official investigation into the uncessary deaths of babies and a mother at a hospital in Morecambe Bay cites 5 ways in which the maternity unit there was dynfunctional. including:Midwifery care became strongly influenced by a small number of dominant midwives whose ‘over-zealous’ pursuit of natural childbirth ‘at any cost’ led at times to unsafe care.

I've seen some commentators point fingers at the Royal College of Midwives campaign eg www.morecambebayinquiry.co.uk/index.php/blog

What's been your experience of the extent to which these things are issues elsewhere in the country, whether you're a patient or a professional? Maybe the tide against the medicalisation of birth and intervention has started to turn too far? Or maybe (hopefully) this is an isolated incident?

FWIW, I'm part of a few online groups geared towards attachement parenting though I'm firmly on a different end of the spectrum to others involved in them who are fervently pro-home birth and anti-intervention and active in groups on those issues too. I can't imagine getting much balanced discussion of this there so posting here instead! I've name-changed too as I may post my own (patient) experience later depending how the thread goes and don't want to out myself!

I didn't think there were more stillbirths either, the stats show progress in reducing stillbirths has stalled over the last 20 years, rather than there being an increase.

I also don't see how stillbirth is related to c section. Professor Nicolaides' work on Doppler scans suggests the stillbirth rates could be dramatically reduced if these were deployed more frequently, and problems with the placenta were picked up much earlier. This has nothing to do with the eventual mode of birth. In addition, there are hospitals with high rates of c-section, who also have very low stillbirth rates, such as Chelsea and Westminster (who have a relatively high number of older mothers).

NoRoomForALittleOne, it will take me a good while, especially since I have a 6 month old. I think its massively important though and I'm quite sick about how over the years how poorly maternity issues are reported through the press. If I don't through it, and try and promote debate on key points who will? I hope a few 'normal people' will. A national review might do some of that but I really think it needs input from women who are members of the public too. I think the actual experiences of women are incredibly important. Its sad that this report itself has come from the terrible experiences of the Titcombe family.

I don't live in the area but my local maternity unit has been under scrutiny recently following a higher than usual number of still births. There was a report following an inquiry there published a couple of weeks ago but it didn't make the national press. So I think it has real importance and isn't just about Morecombe Bay.

I certainly can pick things up from the report which give me thought for reflection. For example.

1.30 At first sight, looking only at the summary outcome of each incident, the differences seem clear: two maternal deaths from different causes, an intrapartum stillbirth, the death of a baby from sepsis, and a baby damaged by shortage of oxygen in labour. Yet on closer examination, the underlying factors show the same pattern: failure to monitor the condition of mothers and babies properly; failure to recognise signs of clinical deterioration; failure to take effective action in response to developing clinical problems; and failure to communicate effectively within and between clinical teams. It seems to us, however, that excessive reliance was placed on the superficial differences in outcome, and little or no consideration was given to the underlying human and behavioural factors that lay behind those outcomes. The chief executive’s view was that there was no link evident at the time: “I was convinced that the circumstances were different, and there was a different reason for them. You know, when you look back, five, six years later you can say well, actually, you know, were they a symptom of the same type of – the same thing. But, at the time, I definitely believed that we – we had worked out what had gone wrong, or what hadn’t gone wrong…” We asked the maternity risk manager. “Do you want the honest answer? Depends what day you ask me.” On further questioning, it was clear that she continued to rely on the clinically different nature of the outcomes to emphasise the lack of connectedness between the incidents.

Everyone was looking at things from a clinical point of view rather than looking at the basic building blocks of what was happening.

I read this and I think of one of the few criticisms I had of my care.

I went to a different trust to where I live to give birth. This meant that my community midwives were familiar with different systems and paperwork. I frequently had to point out the relevant information on my notes. Standardisation of documentation would have made a massive difference. Its a simple thing but would have made several things a lot easier.

Given that women are allowed and sometimes encouraged to use facilities in different areas - particularly if the nearest maternity unit is not the most appropriate for their high/low risk level - I think this needs to change.

I had letters and blood test results walk too so I had to be vigilant chasing things up. My midwives on the whole did do a great job communicating but it would be so easy for things to fall between cracks if there was a more serious problem.

I should also probably point out that this is a particular problem to maternity as you can't choose treatment for other health issues in other Trust areas in the same way.

I also don't see how stillbirth is related to c section. Professor Nicolaides' work on Doppler scans suggests the stillbirth rates could be dramatically reduced if these were deployed more frequently, and problems with the placenta were picked up much earlier. This has nothing to do with the eventual mode of birth. In addition, there are hospitals with high rates of c-section, who also have very low stillbirth rates, such as Chelsea and Westminster (who have a relatively high number of older mothers).

The criticism with the particular cases in the report was to overlook risk factors and problems because the method of birth was more important than anything else, which is why its important here. Referrals were not made that should have been because success was measured by the method of birth rather than whether there was a healthy mother and child at the end of it.

This stems from the belief that CS = bad therefore we should not risk involving doctors (or indeed engage with the woman to inform her) because doctors are more likely to intervene. Rather than the belief that we should involve doctors, work with them to assess the situation before determining what course of action we should take with full discussion and involvement of the woman.

So trying to avoid a CS at all costs can be related to stillbirths because the focus of care is misplaced rather than still births being related directly to CS.

Yes, I agree with you RedToothBrush that trying to avoid a CS at all costs can be related to stillbirth. I was responding more to minifingers posts, from which I got the impression she was saying that 'overmedicalising' birth led to increased stillbirth. I would take issue with that, as induction/ assisted deliveries/c-section can and do prevent stillbirth, whereas the issues you've highlighted from the report - where women were pushed/forced to avoid 'overmedicalisation' whether they wanted it or not, and whether this was safe or not - have obviously led to increased intrapartum stillbirth at this hospital.

It seems that the ideological agendas of certain of the midwifery staff here were irresponsibly placed ahead of safety and the wishes of the mothers. It is such a sad story.

"So trying to avoid a CS at all costs"

I think you'd be hard pressed to find a midwife who thinks c/s should be avoided 'at all costs' or that they either deliberately or unintentionally put mothers and babies at risk by trying to help them avoid intervention.

The point of my post was this: huge increases in interventions haven't reduced the risk of stillbirth in 20 years.

Incidentally, there may well be higher rates of stillbirth in women who've had a c/s in previous pregnancies, unrelated to the cause of the c/s first time around. I don't know why this possibility or big increases in the highly dangerous condition placenta acreta is rarely acknowledged in discussion about the rising c-section rate.

The comment made by an interviewee as they left the room that - “sometimes bad things happen in maternity – people just have to accept it” is chilling.

I think when you are talking about people dying in such a flippant manner it is very dangerous and you really shouldn't be working in any kind of "patient care". Such a comment, albeit reproduced here in isolation, conveys a complete emotional detachment from your duty as a care-giver. We all know what happens when people are dehumanised and I think that's what happened here.

It was also, it seems,something of an institutionalised way of working, blinkered and one which failed to account for patients' individual needs, particularly if these clashed with the midwives' values.

I was disappointed that only one case is being pursued by the Police-presumably as manslaughter?

I also think the midwives have been hung, drawn and quartered in the report and wonder what evidence this was based on and from whom.

I would like to know more about how this report was authored.

Reading the Kirkup report as a midwife (only a quarter of the way through), what strikes me is, a group of strong minded misguided individuals, combined with a group of weaker individuals (the medical staff) - and seniority or experience can not be cited as an excuse as 3/4 consultants were aware of issurs bur didn't act. This clash of misguided personalities, combined with a protective attitude and blurring of roles led to this 'perfect storm' where these mothers and babies were allowed to die and for this to be essentially covered up. It's scary. But it isn't representative of the units I've worked in.

minifingers I will be having an ELCS, and my consultant did cover the risks for subsequent pregnancies, as part of a wider discussion of the overall risks and advantages of both vaginal birth and c section. IMO this is as it should be - nobody should be given just the risks of c section, without also being given the benefits and the risks and benefits of vaginal birth. Or vice versa. I have heard of mothers being given horror stories about the risks of c section, while the risks of vaginal birth are glossed over. Ultimately, I believe all information should be provided in as unbiased a way as possible, albeit there are not reliable stats available for some things.

It seems to me that many people at Morecambe were responsible for these appalling failings: the midwives for their dangerously blinkered, ideological stance; the consultants for not taking charge and allowing them to rule the roost; and the management for not spotting the problems much sooner.

So the Consultants should shoulder much more of the blame too? It does sound from reading the reports in the Press that they have rather let the midwives take the rap, when the whole place sounds to be a mess.

And of course, this also highlights the problems across the NHS more widely with whistleblowing, in that anybody raising concerns/whistleblowing is ostracised and sometimes hounded out of their job. Too often, they are viewed as troublemakers rather than people who care about patients and want their care to be improved.

Absolutely, whilst the behaviour of the midwives was abhorrent, and I am not defending it in any way at all, 3/4 consultants did absolutely nothing (only read a quarter of the report so apologies if I have this wrong) to stop this systemic abuse of protocol and guidelines. It's a huge failure of this trust and this hospital and not symptomatic of maternity services as a whole (in my opinion).

1.14 First, following the intrapartum stillbirth of Alex Davey-Brady in mid-2008, an obstetric consultant, Prabas Misra, wrote a letter identifying some of the deficiencies that had contributed to the disastrous outcome, drawing a parallel with the early neonatal death in 2004 of Elleanor Bennett and warning that in his view further tragedies would ensue unless action followed.11 His letter was addressed to the Clinical Director, Ibrahim Hussein, and copied to the Trust’s Medical Director, Peter Dyer, and others. He did not receive a reply, and we could find no evidence that his concerns were taken seriously, acted upon or investigated: a meeting did subsequently take place to discuss the midwifery report of the incident, but none of the matters that he had raised were alluded to in the record of the meeting. We heard two different versions of the origin of the letter: either Mr Misra wrote it in an attempt to bring problems to light, or he was prompted to do so by Mr Hussein, who wanted concerns about the unit’s functioning placed on record. In light of the lack of any documented response or recorded action following the investigation meeting, it cannot be said to have been effective.

1.19 Based on what we heard, we believe that staff reinforced each other’s view that the care they were providing was acceptable, not sub-optimal. The midwifery staff were already a close-knit group (we heard that off-duty midwives would drop into the unit just to chat), and it is clear that in response to this perceived external threat they developed a ‘one for all’ approach, and in fact described themselves as “the musketeers”.18 We were particularly concerned at the conflicts of interest surrounding the position of maternity risk manager, who was also a supervisor of midwives: we believe that she was part of the close-knit midwifery group of ‘musketeers’ and, as a former Royal College of Midwives union official had continued to act in a staff representative role supporting individual midwives. She was central to deciding whether and how incidents would be investigated, often by herself: “If there was any sort of serious incident or an incident where staff needed support or I needed to start an investigation I would go to that site as soon as possible.” This inherent blurring of roles was graphically illustrated in a letter following a medication error in 2007 to the midwife concerned: “Jeanette Parkinson [Maternity Risk Manager] was present at the meeting yesterday evening (10/1/07) and explained that she was there as your representative

1.20 We do not believe that it is possible to combine roles in this way without a significant loss of objectivity. Given the central role of the maternity risk manager in following up incidents and providing assurance to the head of midwifery of safe and effective practice, in our view the remarkable conflicts of interest inherent in a single individual combining the roles of risk manager, supervisor of midwives, senior midwife and staff-side representative were unacceptable. We believe that this was significant in the events that developed, not only in encouraging the group think amongst midwives that all was well but also in promoting a view at more senior levels that there were no systemic problems in the unit.

1.21 Second, the strong view amongst staff that they were being unfairly criticised on occasions became overt hostility to those challenging this view. This underlying feeling was evident at times from the approach taken by interviewees in responding to our questions, and was sometimes apparent in email correspondence. The most notable example is an email from one midwife to another concerning a Nursing and Midwifery Council (NMC) investigation that was entitled “NMC Shit”. There is no excuse for committing such views to the record, but more important is the underlying attitude it illustrates.

Hmmmm...

The very name "midwife-led unit" sets my alarm bells ringing.

No mention of "mother". No mention of "baby".

The name suggests that such a set up is designed for midwives to take centre stage.

Small wonder then that, in such a unit, the servicing of midwife ideology was allowed to take priority.

Before the interests of the mothers and before the interests of the babies.

If I was giving birth again I would want to go somewhere that was "child-centred" or "birth centred", not "midwife led".

I would want to be somewhere where medically qualified staff can be called upon quickly to assess, intervene and treat in the event of unexpected complications arising.

It's clear from what happened at this MLU that some midwives are more interested in pursuing their own ideological "midwife led" agenda and clearly feel that they have "failed" if intervention by, God forbid, a doctor, is resorted to.

Can't stop thinking about all those dead mothers. All those dead babies.

So many of them avoidable...

Zavi midwife led is as distinct from consultant led I suppose but I entirely agree that the title in both instances should indeed focus on the mother and her infant.

The phrase I'm familiar with is woman-centre cared which I like. I like it because the phrase makes no judgement or preference.

Its why I picked the hospital I did, rather than others closed that said things on their website like 'proud of our low CS rate'. The terminology and promotion like that tells a bigger story.

It's called 'midwife led' because midwives are the lead professionals in those settings.

Do you also have a problem with 'Consultant Led'?

I think this report will lead to paranoia and defensive practice among midwives and to care which is inflexible and completely protocol driven. Many mothers exposed to this sort of protocol driven care will suffer because of it.

But it seems I'm in a minority. Most people don't seem to want midwives to have autonomy and use their judgement in a situation where adhering to strict protocol might make a labour more traumatic, difficult or dysfunctional, just in case .

I tend to agree mini fingers, there has been talk of 'rebranding' midwives as obstetric nurses , which will mean stripping us of our autonomy and giving women far fewer options but it seems as though this is what women want and whilst I don't know if we fully understand the implications of this we are supposed to be a women centred profession with their needs and wants paramount. I don't know how this can be reconciled in the current model of midwifery.

I have never understood why midwives decide the risk level. I would have thought everyone should be reviewed by a doctor with either an in person appointment or a review of case notes would make more sense.

It was a doctor with 11 years of education and over 20 years of experience that got me through my first pregnancy. We were supposed to move to the UK midway through my pregnancy. I made some calls and the only hospital in the North West that I would consider is Liverpool Woman's hospital. The others, wythenshaw in particular, were staffed by mean, nasty and miserable midwives. Apparently if you can't push a baby out you weren't worthy of being a mother (wythenshaw gem).

Because midwives are trained extensively in childbirth and pregnancy, they have a sphere of practice in which they are the expert, they should be able to recognise when something falls out of that remit and then refer them on to a more appropriate source of care (ie high risk becoming consultant led) you don't need a doctor to do it as in that respect midwives are just as qualified to do so.

When I say doctor I mean an obn. I had my kids here in the us and a midwife led unit is an option for some. I asked about it and my obn said I could consider it down the road if I remain low risk. As it turned out I wasn't low risk.

An obn has had 8 years of training compared to a midwife who had 3-4 years training. I would have thought it makes more sense for the doctor to determine if the patients are low or high risk.

Whilst I respect that opinion it's worth pointing out here obstetricians deal solely in high risk whereas midwives deal with and are the experts in low risk, that's not to say both can't recognise the other but they each have their own sphere of practice that they are trained to recognise.

So if midwives are the experts for low risk why are they the ones to pick out those who are high risk? If the obns are the ones dealing with high risk and that is their specialty than surely it makes sense for them to review notes or examine all.