Baby Loss Awareness Week

I beg to move,

That this House has considered Baby Loss Awareness Week.

I thank the Backbench Business Committee and all those who have supported this important debate. In particular, I thank the hon. Member for Sheffield, Hallam (Olivia Blake), who, unfortunately and unexpectedly, has been unable to attend. She sends her apologies to Mr Speaker for that. I also wish to thank the hon. Member for Truro and Falmouth (Cherilyn Mackrory), my co-chair of the all-party parliamentary group on baby loss. She is a font of inspiration, guidance and support, and I thank her for that. I joined the APPG shortly after being elected and became its co-chair earlier this year. I joined because many of my constituents had suffered the loss of a baby at Shrewsbury and Telford Hospital NHS Trust, and the Ockenden report on systemic failings there revealed that many women—indeed, whole families in Shropshire and the surrounding area—had suffered a devastating loss that was avoidable.

Baby Loss Awareness Week—which took place last week, while we were still in recess, but which we are marking with this debate—is an important moment to support any family who has lost their baby and to ask ourselves whether anything more can be done to prevent other families suffering this heartbreak. This time last year we debated the findings of the Ockenden report—most importantly, the need for safe staffing levels in maternity units across the country. One year on, I ask the Minister to update us specifically on the progress made and on the outlook for maternity services and safe levels of staffing in the future. Unfortunately, since the debate last year we have been starkly reminded that poor maternity care was not restricted to Shropshire. Dr Bill Kirkup has reported on his findings at East Kent and Donna Ockenden is currently reviewing issues at Nottingham, which threaten to be on an even greater scale than those at Shrewsbury and Telford.

Each time a scandal emerges, we promise ourselves that it will be the last time, but tragically that has not been the case so far. Far from being a localised issue, it seems that maternity services have been experiencing a crisis nationally. In 2022, 38% of maternity services were rated by the Care Quality Commission as inadequate or requiring improvement. The avoidable death of a baby is something we should be working to eliminate.

Earlier this year, I attended the launch of the joint report by Sands and Tommy’s joint policy unit on progress on saving babies’ lives. The headline of that report is that the Government are not on track to meet their target of halving stillbirths, maternal deaths, neonatal deaths and serious brain injury from their 2010 levels by 2025, and there is no target for further improvement beyond 2025. The report also showed that in 2021 there were 13 babies per day who were stillborn or died within the first 28 days of life across the UK. In 2021-22, nearly a fifth of stillbirths were found to have been potentially avoidable if better care had been provided, and two thirds of action plans created following the death of a baby are rated as weak. Too often, avoidable losses continue to occur as a result of care that is not in line with National Institute for Health and Care Excellence guidance. For example, data for England show that 40% of women and birthing people do not attend their antenatal assessment before 10 weeks’ gestation, as is recommended in the NICE guidelines.

Research must be the key to improving outcomes and saving more babies’ lives in the future, yet relatively little is invested in pregnancy-related research. For every £1 spent on maternity care in the NHS, only 1p is spent on pregnancy research. Worse, health inequalities are stark when we look at baby loss. Black babies are twice as likely to die in their first 28 days as white babies, and black ethnicity is associated with a 43% higher rate of miscarriage than white ethnicity. In England and Wales, in 2021 the stillbirth rate for women from the black African ethnic group was seven per 1,000 births, which would have to reduce by more than 60% in four years to meet the 2025 overall population target of 2.6 per 1,000 births. Stillbirths are almost double the level among people living in deprived areas in the UK than they are among those in the least deprived areas.

There is also a real lack of evidence in this area. Much of the national data is based on aggregated ethnic groups or broad categories of deprivation, which provide limited insights into individual lives. Despite the Government’s commitment to levelling up, there are no national targets and no long-term funding for reducing inequalities between ethnic groups or areas of deprivation. I know that the Minister has read that report and engaged seriously with these issues, and I urge her to consider its recommendations in full.

My constituents Kayleigh and Colin Griffiths, along with Rhiannon Davies and Richard Stanton from Telford, campaigned tirelessly for the Shrewsbury and Telford Hospital NHS Trust review, and I was pleased that they were each awarded an MBE earlier this year in recognition of their efforts to ensure that parents’ voices were heard and that babies born in future would be safer. They have reflected on the new concerns that have come to light and have written to the Secretary of State to request a public inquiry into maternity services in England, given the apparently alarming scale of the national problem. Unfortunately, they have not yet received a response to that letter. Will the Minister confirm whether the Secretary of State will be replying to that letter, and whether the Government will consider nationwide action to fully understand why maternity services have come under so much pressure and how to prevent avoidable baby deaths in future?

We should always remember that these are not statistics but the horrific experiences of women at their most vulnerable. A constituent wrote to me this week following her own experience at Shrewsbury and Telford, one about which Donna Ockenden’s team concluded that different management would reasonably have been expected to have made a difference to the outcome. My constituent said:

“My son was born 10 days overdue on 7th August 2007 in Shrewsbury hospital. Unfortunately, due to gross negligence by the trust that day I left their hospital with empty arms and a broken heart.”

Shrewsbury and Telford Hospital NHS Trust accepted all the findings of the Ockenden report and regularly reports its progress against the recommendations. I am in regular contact with the trust’s team, and they reported that 75% of the recommendations in the report had been delivered and assured, and that there is good progress on the remainder. Of the recommendations in the earlier first report, 88% have been implemented and assured, and I have also received assurances that staffing levels in the maternity service are at an acceptable level. However, Donna Ockenden also recommended immediate and essential actions for the whole of the UK in both her first and second reports. I hope the Minister will be able to provide us with an update on progress on those actions, particularly on safe staffing, training and culture within the maternity service.

I also want to consider those awful circumstances where the loss of a baby is unavoidable and the cause often unknown. In 2021, the cause of 33% of stillbirths and 7% of neonatal deaths was unclear. The all-party group on baby loss has heard devastating evidence from parents who have been left in limbo for months or even years waiting to find out why their baby died, because of a desperate shortage of perinatal pathologists. A survey conducted by Sands in 2022 found that delays in parents receiving post-mortem results have significantly worsened over time. More than a fifth of parents reported waiting up to six months or more for the result of their baby’s post-mortem.

In October 2022, an interim policy for the commissioning of perinatal post-mortems was adopted, which defines inclusion and exclusion criteria as to which cases will be offered a perinatal post-mortem. Since this policy was adopted, no audit of the impact has been undertaken, with NHS England acknowledging that communication of the interim policy has fallen short. Sands has received anecdotal evidence of consent takers being unaware of the new approach and it is concerned that that has led to parents not being fully informed about consent.

There are currently just under 50 full-time equivalent paediatric and perinatal pathology consultants in post in the UK, with an additional 15 vacant consultant posts. The number of current trainees is insufficient to fill these vacancies according to the Royal College of Pathologists. Will the Minister provide a clear commitment and timeline for the recruitment of perinatal pathologists, to ensure that no bereaved parent ever has to wait more than six months for post-mortem results?

It is obvious that staffing remains the single most important issue for maternity services. In a survey commissioned by the Sands and Tommy’s joint policy unit, 84% of midwives who were asked disagreed that there were enough staff around them for them to do their jobs properly. A decrease in staffing levels has been down to staff sickness rates over time and job satisfaction. In 2022, 63% of midwives in England had felt unwell in the past 12 months because of stress.

NHS England has recently published its long-term workforce plan and the Government have provided an initial financial commitment of £2.4 billion over the next five years to fund education and training. Will the Minister consider the importance of long-term recurrent funding, as well as investment in retention? Without that, there is a risk of losing valuable experience and skills in the existing workforce. The workforce plan models the number of future midwives required, but does not include other staff groups, which risks ignoring some of the areas and specialisms in the wider maternity and neonatal workforce, where staffing issues are most acute.

We all know there is no magic money tree, but it is a false economy to continue to deliver services that are potentially unsafe. According to Sands, the cost of harm from clinical negligence caused by NHS maternity services was £8.2 billion in 2021/22—60% of the total cost of harm from clinical negligence in the NHS and more than double what the health service spends on maternity care in the first place. The cost of failure is always so much higher than the cost of success.

In conclusion, while the Government’s commitment to the recommendations of the Ockenden report was welcome, there is a still a long way to go to deliver world- class maternity services and meet the Government’s own target of halving baby loss by 2025. Too often, harm continues to occur as a result of care that is not in line with nationally agreed standards. Listening to the voices and experience of families must be at the heart of policy, but most importantly we must ensure staffing levels are safe, so that no one leaves hospital with empty arms and a broken heart, where that might have been avoided.

It is a pleasure to speak on this important subject. I pay tribute to the hon. Members for Sheffield, Hallam (Olivia Blake) and for North Shropshire (Helen Morgan), and the others who have secured the debate. It has become something of a tradition that we mark Baby Loss Awareness Week, although we were not able to do so last week because of the recess.

This has also become one of the more emotional and harrowing debates—I have sat through many debates over many years—which is a great tribute to how this place has progressed. When I first came to this House all those years ago, as you did, Madam Deputy Speaker, baby loss was a subject that was not discussed. Certainly, the personal experiences of Members, particularly female Members, going through the trauma we heard about in the earlier debate and through baby loss generally, let alone the experience of partners, did not come out into the open. The stigma surrounding mental health meant that no Member of Parliament would dare to raise in public the fact that they might have some mental illness problems. Why would they not? A lot of the population have such problems, and we are just humans like the rest of the population, doing a particularly stressful job.

The progress that we have made over the 26 and a half years that we have been in Parliament, Madam Deputy Speaker, is a real tribute to this place, and to the bravery and openness of hon. Members who have come forward with their personal experiences. Those experiences enrich the way in which we scrutinise Government Departments, rules, regulations and legislation that needs to be brought in to deal with related problems. I pay tribute to all those who have shared their experiences. I was listening to the previous debate in my room, in between meetings, and I particularly pay tribute to my hon. Friend the Member for Stafford (Theo Clarke), as she said it was the first time that the specific issue of birth trauma had been mentioned here. She opened up incredibly emotionally about her own experiences.

Does my hon. Friend agree that the fact that aftercare for fathers is often lacking places a huge burden on relationships? Sadly, the statistics show that 50% of relationships can break down after the loss of a baby. Does he agree that we need to do much more to support fathers, as well as mothers, after the loss of a baby?

My hon. Friend, who again has great experience and has been exceedingly forward with her own experiences, is absolutely right. There have been many studies on maternal perinatal mental health problems. The latest estimate is that that costs this country over £8 billion, and there has been an increase in perinatal mental health problems among women, exacerbated by the lockdown.

As happened to our own colleagues, for many months babies born during lockdown did not come into contact with another baby, or with extended family members such as grandparents, who would usually be at the hospital bedside to welcome a new baby, but were not allowed to be there. Speaking as the chairman of the all-party parliamentary group for conception to age two: first 1001 days, we are only starting to see the considerable impact of that on babies. We will only start to see that as those babies grow up and go to school.

However, there have not been as many studies about the impact on the mental health of fathers. There is good evidence to suggest that fathers can suffer considerably, yet the support networks, which are still not good enough for mums, are not nearly good enough for fathers. It is a false economy not to support that.

In a minute, I want to have another rant about my Act, the Civil Partnerships, Marriages and Deaths (Registration etc) Act 2019—that is the real reason for my coming to this debate, although I always try to take part, because the Act deals with stillbirth, in particular—but first I will make some general comments.

It is good that we are discussing this issue and that the profile is so much higher than it has been in previous years, but there is a lot of work still to do. The stillbirth rates have come down and there has been progress. Back in 1993, there were 5.7 stillbirths per 1,000 births. There were 2,866 stillbirths in 2021, so the figure is now about 3.8 or 3.9 stillbirths per 1,000 births. There has been progress, but in order to get to the target under the national maternity safety ambitions, which was launched in 2015, we need to get that figure down to about 2.6 by 2025, so there is a lot of work still to do on stillbirths.

The hon. Gentleman is correct in what he is saying. Does he agree that one of the problems across the UK is that, on the whole, most of the stillbirths we have are preventable? When mistakes occur, as they inevitably will at times, there is a culture of cover-up and secrecy, so the lessons that need to be learned are not being learned, because NHS trusts and health boards are too busy trying to cover their backs rather than finding out what went wrong.

The hon. Lady gallops way ahead of me; I will come on to speak about that. That is what my private Member’s Bill, now an Act, seeks to address, so I will come back to those comments.

Stillbirths are not the only issue. Progress has been poor on neonatal death rates, which have plateaued for some years and are even further away from coming down to those 2025 targets. There were 1,719 neonatal deaths last year—that is deaths within 28 days of being born. There is also the whole subject of miscarriage. I will not go into great detail on that, but we know that at least one in five pregnancies end in miscarriage, and there are probably more that we do not know about. The Government have done a lot of good work on this. I pay tribute to the former Health and Social Care Secretary, now Chancellor of the Exchequer, for his emphasis on safety in hospitals, particularly safety around maternity, and for the launch of the Safer Care Maternity action plan back in 2016, which were all about improvements in maternity safety training. The Our Chance campaign was targeted at pregnant women and their families to raise awareness of symptoms that can lead to stillbirth.

The inauguration of bereavement suites in hospitals was another important development—I have seen my own in Worthing. It was wholly unsatisfactory that a woman, following a stillbirth, would be placed in a bed next to a mother who had fortunately had a healthy, screaming baby. The impact on the mother and the father of having a stillbirth and then seeing the reverse was traumatic and had to be dealt with. The bereavement suites provided a more discreet, private area, away from those mums lucky enough to have healthy babies.

I am grateful to my hon. Friend for giving way. It allows me the opportunity to welcome the fact that, last week, NHS Grampian announced the upgrading of the bereavement suite at Dr Gray’s Hospital. Marsha Dean from Elgin, one of two bereavement specialist midwives in the NHS Grampian area, welcomed that. Tina Megevand from Moray Sands said, “It’s so very important that anyone affected by pregnancy loss or death of a baby gets the best possible bereavement care and is offered a safe, protected space to spend time and make memories with their baby.” What my hon. Friend has just said is crucial and I just wanted to put on record our appreciation in Moray for having such a facility.

I am grateful to my hon. Friend for putting on record what his local hospital is doing, and I hope that that is happening around the country. Certainly, my own hospital takes great pride in its bereavement suites and they have made a big difference to the impact on parents in its maternity wing.

We have had the Ockenden report as well as the Cumberlege review, so there has been a lot of activity from the Department of Health and Social Care, but we need to go so much further. Although I will not go into detail here, I wish to reference the high incidence of stillbirths and baby loss among the black, Asian and minority ethnic community, who are something like five times less likely to receive maternal aftercare.

As hon. Members have mentioned, there are also real challenges and big vacancies in the midwifery workforce. As has been said, 38% of maternity services have been rated as requiring improvements in safety, so there is still a long way to go. One thing that has particularly alarmed me—I am sure other hon. Members will have had the briefing from that excellent charity, Sands—is the state of perinatal pathology. I think my hon. Friend the Member for Truro and Falmouth (Cherilyn Mackrory) may be talking further on that. Currently, there is a significant proportion of parents who have to wait more than three to six months for their babies’ post mortem to be undertaken and for the results to be communicated to them. Those waiting times are then further exacerbated by poor communications about what is happening. Having gone through the trauma of losing a newborn baby, parents then have to wait a long time to find out what happened, which causes them additional trauma.

As I mentioned earlier, there is the whole issue of mental illness and, in particular, the impact of mental illness and depression and the prevalence among teenage mothers. It is important that we deal with that early and that the support is there because we know—the Minister mentioned this in the previous debate—about the high incidence of suicide linked to the perinatal period.

My hon. Friend is making brilliant points, which I am so grateful for. Does he agree that those healthcare professionals will probably welcome this because it will start to break down the blame culture that the hon. Member for North Ayrshire and Arran (Patricia Gibson) talked about?

My hon. Friend is absolutely right. We do not want a blame game. When I was the Minister for Children and we reviewed extraordinary and harrowing child deaths at the hands of various people, it was the blame game for social workers that so undermined the profession. It is not social workers who kill children; it is carers and others with evil intent. But where there has been incompetence, where the system has perhaps contributed to that incompetence or has effectively obstructed a professional from getting on with their job in the way that they would like to and can do, that is where we need the findings. In some cases, that may require a coronial investigation, which can look under every stone and really get down to the roots of the problems, rather than just point a finger of blame with which the whole profession gets tarred.

That is why—you will be relieved to hear, Madam Deputy Speaker, that I am about to end—my Bill, if I do say so myself, brought in some important and necessary changes in the law, most of which have happened, have been welcomed and have gone very well. This change was widely welcomed, but has not been enacted, and the need for it to be enacted has never been greater.

Back in 2019, ahead of the December election, I had promised couples that the regulations to allow civil partnerships would be brought in before the end of the year. On the last day before Parliament was dissolved, those regulations were brought to the Floor of the House, and I had to move them—that would normally be done in Committee—in order to get them through in time with the help of the Chief whip. I do not want to have to do the same at the very last breath just ahead of the 2024 election, because there is no excuse for this not having happened several years ago.

I plead with the Minister. She supports these changes. The Government support these changes. This Parliament—both Houses—supports these changes. Parents, professionals and coroners support these changes. Why is she not getting on with bringing them in? Please, please, please knock heads together across both Departments and get these regulations laid, get the consultation results published, and let us bring in an additional layer of safety for parents who go through the trauma of stillbirth and have unanswered questions when they leave hospital without the child that they had hoped they would leave with.

It is a great honour to follow my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton), who set out very clearly his work in this space, for which I am very grateful. I extend an offer to him to use the all-party parliamentary group on baby loss for anything that we can do to help bring about the conclusion that he requires, because I believe he is absolutely right.

I am incredibly grateful to my APPG co-chair, the hon. Member for North Shropshire (Helen Morgan), for requesting this debate and to the Backbench Business Committee for allowing it today. As my hon. Friend the Member for East Worthing and Shoreham has already said, it is now a tradition in this place to set aside time to discuss Baby Loss Awareness Week. I have had the privilege of chairing the APPG on baby loss for the last three years, and I also chair the all-party parliamentary group on women's health, which means that much of my time in this place is taken up with supporting women and families through some truly uncomfortable and sometimes deeply unpleasant experiences.

As colleagues may already be aware, Baby Loss Awareness Week was last week, when the House was in recess, but this debate is now marked in the calendar of this place. I know that many right hon. and hon. Friends are in other places today for many good reasons, but there is normally a lot of collaboration across the Benches. We forget party politics and talk about what is important. This debate should be a tradition in this place because it shows Parliament at its best. Not only does it allow the general public to remember that we are all human, but it also means that tribal party politics is put aside, allowing us to try to work together on these important issues.

I want to place on the record my sincere thanks to the APPG for the work that it did before my time in this place under the guidance of my right hon. and learned Friend the Member for Banbury (Victoria Prentis), now the Attorney General, and my hon. Friend the Member for Colchester (Will Quince). Both of them gave powerful testimonies in this place before I arrived. I also thank my former co-chair on the APPG, now Chancellor of the Exchequer, my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who has such a passion for this topic from his time as Health Secretary. It is through his actions that we are now seeing the NHS workforce plan come to fruition. It was a deeply held passion of his, and it is the key to unlocking a lot of what we talk about in this space.

The APPG, again before my time, established the national bereavement care pathway to improve bereavement care and reduce variabilities throughout the country. It has been adopted by the majority of trusts, but it is a constant challenge to ensure that it is maintained given all the competing priorities facing the NHS. I ask the local health leaders watching the debate today to please understand how important the pathway is. We have had two debates in the Chamber this afternoon on topics that affect so many women and so many families. I ask local health leaders not to put the pathway to one side because it could be a cost-saving exercise in their trust.

I want to re-emphasise that point because it is so important. When a baby goes for a post-mortem examination, it is in transit and away from its parents. The parents are often unable to keep track of the remains of their baby and when they will get them back. Does the hon. Lady agree that we need to beef up that whole process to give parents the support that they need at such a difficult time?

I agree wholeheartedly. There are a couple of ways in which we can do that. One is the roll-out and expansion to all centres of minimally invasive autopsies and other non-invasive techniques. Not all post-mortems need to be invasive. Certainly, there needs to be an expansion of placental autopsies—if that is the right phrase—because the cause can often be found that way without the need to keep the baby for an awfully long time. We can do a lot more work in that space. The pathologists we have spoken to all want that work to be done, and if they had more time, they would be able to do more research on why it happens. At the moment, a baby could be lost at 38 or 40 weeks for absolutely no reason at all, and the parents will never find out why. Blame can be thrown around for the different things that happened on the day of the birth, but we just do not know the reason, and that is not acceptable in 2023. We will never find out every reason for every lost baby, but we could do an awful lot better.

I am told by Sands, the baby loss charity, that the shortage of perinatal pathologists has been growing over decades, and in recent years, mutual aid between pathology centres has reduced the impact on the national delivery of services, but that approach is breaking down as the capacity of overburdened centres to pick up cases beyond their own areas is dwindling. I cannot see that getting better without direct help in the near future.

We also need to get the basics right. The Royal Cornwall Hospital in Truro has the Daisy suite, which is a separate bereavement suite of rooms for those who lose their babies. It has its own bathroom and kitchen—not to put too fine a point on it, but being in labour puts extra pressure on your bowels and bladder, and you can be sick a lot. Being in that space is better not only to face the trauma, but because you do not have to see other parents holding their live babies. That was not available when I was going through the process of losing our baby. There was a girl there by herself—a young mum—who was 38 weeks pregnant when her baby had just stopped moving. Suddenly, I felt very well supported because I had someone there with me. Although we had a room to ourselves, I had to troop and up down the corridor to the bathroom, and I saw healthy babies, pregnant women who were glowing, and families who were just looking forward to taking their babies home. That is just too much to process, so I would be very grateful if we could avoid that. I was surprised to hear this week that the Snowdrop unit at Derriford Hospital has only just opened, but I am so pleased that parents in Plymouth can now make use of it at a time when they will be at their lowest.

This week, a colleague mentioned a constituent of hers who had delivered a stillborn baby and was left on a normal maternity ward—that is unacceptable. The woman was cradling her stillborn baby and people would walk past and congratulate her on the birth because they had no idea that her baby was not alive. She did not know what to say, so she just sort of nodded. Why, oh why, was that poor woman left in that vulnerable state? Most bereavement suites are funded with charitable donations, perhaps with some departmental funding. We need to get the basics right and in place. Although we cannot get everything right quickly, we can easily make things better.

I did not mean to interrupt the hon. Lady. I am so grateful to her for giving way. Before she ends, I just want to commend her on picking up the mantle as one of the chairs of the all-party group on baby loss. I was one of the founding members, along with the right hon. and learned Member for Banbury (Victoria Prentis), the right hon. Member for Chichester (Gillian Keegan) and the former Member for Eddisbury, Antoinette Sandbach. We all got together as parents who had been through baby loss and set up the all-party group. I am not as involved now as I would like to be, but I commend the hon. Member for Truro and Falmouth (Cherilyn Mackrory) for her energy and enthusiasm in keeping it going.

While I am on my feet, I have to commend the hon. Member for East Worthing and Shoreham (Tim Loughton) for his absolute, total commitment and drive for the last six-plus years in trying to get all elements of his private Member’s Bill through the House—those that have been passed by the House but are still not fully through. I disclosed my baby loss in the debate on his private Member’s Bill in 2017. I lost my baby 25 years ago, but the first time I talked about it really outside my immediate family was in 2017—I know the hon. Lady mentioned that point. I commend him, and I honestly hope that when the Minister responds we will get some good news on some of those final measures.

I am really grateful to the hon. Lady for sharing that with me. I apologise; I knew there would be so many Members I missed off my list. It is an open thank you to everybody who set up that APPG. I also did not mention the hon. Member for North Ayrshire and Arran (Patricia Gibson), who is here every year for the baby loss awareness debate and constantly reminds us of her loss. Baby Loss Awareness Week is not easy. We do it because we want to help other people, but it always brings it back. It was very raw for me on Sunday at the service in Truro and also for my mum. I pay tribute to everybody who works in this space. As I said in the previous debate to my hon. Friend the Member for Stafford (Theo Clarke), who is new on this journey, you have to look after yourself so that you can look after other people.

I will conclude. There is so much we can do here. I am glad the Minister is listening—she always is—and I look forward to working with her and anybody else who wants to, because we have to get it right for everybody, everywhere.