My Lords, I am pleased to have this debate today. I thank those who have put their names down to speak. It is really interesting to see the level of expertise on this subject here, which proves the value of this House in contributing to wider debates.
One of the reasons that I wanted to discuss this issue was the pressure on maternity services that I have been hearing about in my local area. In Kirklees, we have no NHS birthing facilities whatever; it is one of the largest metropolitan areas in the country. The unit at Huddersfield Royal Infirmary was suspended more than 12 months ago and the Brontë Birth Centre in my former constituency of Dewsbury, whose opening I remember with a fanfare as something to be celebrated, has been closed since August 2022. The basic reasons for these closures have been the crisis in staffing and the level of staffing shortages. The local trust is trying to reopen the Brontë centre, working with a neighbourhood trust, but the problems of staffing are having a real input and will be a deciding factor.
No one can doubt the critical importance of maternity services. Those of us who have given birth will recall many details, good and less good, of that experience. The experience of maternity care can affect the future of both mother and baby. A difficult birth experience can affect bonding and early relationships—a point emphasised to us by the Royal College of Psychiatrists. Everybody who is involved in maternity services will know the significant responsibility that they have. Thankfully, most pregnancies end in the birth of a healthy baby, although that in itself does not mean that the mother’s experience has been optimal. On the other hand, some expectant mothers have their own views of what their experience should be; sometimes, those views are not realistic and can create extra pressure on midwives and others. Locally, I know that the trust has reported more high-risk women wanting births in settings designed for low-risk women, creating extra pressure and highlighting the complex problems that many midwives have to face.
I want to start with the recent important reports on the overall state of our maternity services. The report from the Care Quality Commission is absolutely critical here but I believe we have all received many briefings from mothers of babies, the Maternity & Midwifery Forum, the Nuffield Trust, Mumsnet, SANDS, the Royal College of Obstetricians and Gynaecologists and, of course, the Royal College of Midwives. They have all consistently reported a very alarming situation.
The Care Quality Commission tells us that maternity services were under pressure prior to Covid and that that has worsened. Covid did not help but we cannot continue to use it as an excuse for all the failings in all our services across the board. The pressures on maternity services have been building for more than a decade. The commission also tells us that almost half of all the maternity services inspected in 2023 were rated as either in need of improvement or inadequate—an increase on last year, with things moving in the wrong direction.
My Lords, it gives me great pleasure to follow the noble Baroness, Lady Taylor of Bolton, and thank her for a very interesting and incisive speech. I see that congratulations are being offered to her right now and she deserves them.
One thing that struck me as the noble Baroness was speaking was how important it is that we concentrate on relationships. We must consider all the relationships involved—the parents, the rest of the family and grandparents perhaps—but the most important is the relationship of the staff with the women and their babies. We know that there is huge pressure on midwives at the moment—the noble Baroness raised that issue.
This is a very important debate, and I am extremely pleased that the noble Baroness has taken to the opportunity to raise it. She and many other Members of the House of Lords feel strongly about maternity services and the beginning of new life. The way in which women and their babies are looked after is critical to the well-being of this country. It is a very interesting debate to have raised and I thank her warmly for it.
Maternal mortality rates are at their highest for 20 years. That is quite shocking and really must be addressed. I hope that through this debate we will raise the issues that are important.
I want to say something about when I chaired the National Maternity Review. I was asked to do it by the chief executive of NHS England, who was then Sir Simon Stevens—now the noble Lord, Lord Stevens—and I was given the task of completing the review in nine months, which seemed a very appropriate time. We published our report in 2016 and called it Better Births. It set out five years in which to plan and work towards improving maternity services in England. I was fortunate to have a wonderful, expert group of people on the review team, which was hugely helpful. The important thing we did was to go out and listen to the women of England, their partners and their families, and to the staff who provided maternity services. We listened and we learned from them, not just women who were already mothers but women hoping to become mums in the near future. We heard uplifting, inspiring stories of good maternity care and good outcomes, but we also heard some truly sad stories where care had not been good or outcomes had been devastatingly bad.
My Lords, I thank my noble friend Lady Taylor, for introducing this timely debate. It is an honour to follow the noble Baroness, Lady Cumberlege, with her long and distinguished engagement with many health issues.
I want to highlight some numbers. The Royal College of Midwives estimates that there is a current shortage of midwives across England equivalent to 2,500 full-time staff. While the NHS workforce in England rose by 14.1% between December 2019 and March 2023—that is almost 160,000 full-time equivalent members of staff—the number of midwives over that same period rose by 1.1%, or just 247 additional midwives. The impact of this shortfall, to quote the RCM, is “stark and sobering”.
Staff shortages mean women and their babies are not receiving the high-quality care midwives want to deliver. But it is not just that staffing levels simply have not kept pace with demand. At the same time, a rise in more complex pregnancies—whether due to increasing maternal age, increasing obesity in pregnancy or pre-existing medical conditions, all of which may place women at high risk of complications—has resulted in pregnant women often requiring more care and more time with midwives so that these issues can be picked up.
The last few years have also seen a significant year-on-year drop in students studying nursing, with an inevitable impact on the numbers who go on to midwifery. This is critical because, while steps are now being taken to increase the number of student midwives, the potential positive impact of this is undermined, as my noble friend has said, by too many experienced midwives leaving. Why? It is because they are burned out, insufficiently valued or rewarded, and because they cannot deliver the quality of care they want. In addition, senior midwives are needed to provide oversight and leadership, but this essential career route means losing experienced midwives, which is having an impact on the ability to train student midwives on their NHS placements. Staffing ratios need to reflect the combination of experience and skills needed to deliver care successfully. Within the workforce planning now under way, what review of national staffing ratios is taking place to ensure that we have sufficient staffing and funding for the population that NHS England serves?
My Lords, I thank the noble Baroness, Lady Taylor of Bolton, for initiating the debate today on maternity services in England—or should I say, as has already been mentioned, the woeful state of maternity services in England as evidenced by a series of recent reports on their failings. Although we are debating maternity services, what we are really talking about is the state of care the nation is willing to provide for the mothers of the nation and their babies—the future citizens who will shape our nation.
I should say at the outset that I am well aware that good quality maternity services depend on the care and expertise that the key profession—midwives—provides. The rest of us, including obstetricians like me, are there to support them. I therefore fully subscribe to all the comments made about shortages of midwives and the quality of midwife care.
Before I go any further, I need to declare my interest: I am a lifelong obstetrician. I spent 37 years of my working life being one, and every minute of it was a joy and a pleasure. I would go back to it tomorrow if they let me—but they will not. I am also a fellow of several Royal Colleges, but that is totally irrelevant.
I am pleased to take this opportunity to put on record my eternal gratitude to all the thousands of mothers who afforded me the privilege of being a part of their lives at the most important time of their lives: during their pregnancy and the birth of their baby. I learned that pregnancy and childbirth give a whole new meaning to the word “beautiful”.
I had a special interest in looking after mothers who had preexisting conditions that could affect their pregnancy and the unborn baby, or who developed complications that may have threatened their pregnancy and the life of their baby. I was privileged to be able to do so. Understandably, these mothers were anxious and hoped all would go well. I remember one occasion when I delivered the healthy baby of a first-time mother who had diabetes and had had quite a challenging time during her pregnancy, to say the least. I noticed the pleasure on her face—I have seen it a thousand times; it is quite remarkable when a mother sees her baby for the first time—and I asked her how she felt. After thinking for a minute, she said: “I know the days will be shorter and the nights longer; clothes will be shabbier, but the future will be happier. I will forget the past. The baby will make love stronger. I was a woman yesterday; I am a mother today”. I will never forget that. To witness the joy in her face was a privilege. Sadly, according to recent reports, this is not the case for hundreds, if not thousands, of mothers. It should not be so. We should be ashamed that it is so for even one mother—but it is so for thousands, according to the reports already mentioned.
My Lords, I enter this debate with some trepidation, having heard contributions such as the last from such a distinguished obstetrician, but I thank my noble friend Lady Taylor for introducing the debate.
I echo what the noble Lord, Lord Patel, said: what happens in maternity services should be seen as a bellwether for the rest of the NHS. The CQC reports on maternity services that Members have referred to are really quite shocking. We know that for women who are pregnant, this period forms their view of the confidence they can have in the services that they are relying on during pregnancy. There is more than one: it is not just a midwife, it is the GP, it is whoever they see in community services, it is all the other services that prop up their eventual delivery, and the post-delivery services, that are under the microscope here. During my period of chairing the Public Services Select Committee in this House, in virtually every inquiry, we came across women who felt that their relationship had almost been defined by this during their pregnancy: if it had been a poor experience, that introduced anxiety, concern and just a little trepidation about how they would make sure that their health and that of their family was looked after in future. I wanted to intervene in this debate to tease that out a little more.
I thank all the myriad organisations which have written to us about this debate, but also the Library. We are really privileged to have such high-quality research and attention paid to us. Too often, we take it for granted and forget to say thank you to the Library staff for doing that.
All the reports and briefings highlighted staffing and leadership, as the Public Services Committee did. For me, they underpin this whole thing. There is a crisis in staffing and in the skills mix there needs to be to ensure a happy and successful pregnancy for mother and baby, and there is certainly a crisis in leadership. Far too many of the good leaders have left, partly over Covid and partly because of additional pressures. The workforce plan on its own is not the answer. As the noble Lord, Lord Patel, said, you can have plan after plan and review after review, but without adequate implementation they will be just glorified bits of paper on the shelf.
My Lords, I draw attention to my registered interests in healthcare. I thank the noble Baroness, Lady Taylor, for bringing this important debate to the Chamber. Her speech was an absolutely laser-focused analysis of the current situation and summarised many of the issues that I will return to—without, I hope, too much repetition.
The current state of maternity services in England is of concern to many stakeholders, but this must be put in context. Most expectant mothers and their significant others receive high-quality care during pregnancy and are delivered of healthy babies. However, the latest CQC report rates 10% of maternity services as inadequate and 39% as requiring improvement. This margin of error in such a vital service is really concerning.
Shockingly, safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for safety and 12% rated as inadequate for being well led. I think we can all agree that this is an unacceptable failure of the women, their partners and babies in this country. Of particular note is the fact that poor provision is disproportionately failing many mothers form minority-ethnic groups, as others have outlined, but also white women who suffer economic deprivation.
Many factors contribute to this situation. Part of it might be that there has been less regard for the profession in the last decade than there was. I remember coming to the end of my general nurse training, just 500 yards down the road, and being asked what I was going to do next. I said I wanted to do mental health nursing, and I still remember the sister tutor saying to me, “But you’re bright enough to be a midwife”. We should hold on to that. I am happy to tell you that I got an obstetrics certificate so that I could work abroad and ended up as a mental health sister with a mother and baby unit in that ward—so I actually used it wisely.
My Lords, I thank my noble friend Lady Taylor for initiating this debate with her usual thoroughness and elegance. If the recommendations made by the noble Baroness, Lady Cumberlege, were all implemented, we could go home now. The noble Lord, Lord Patel, nearly made me cry. This is a very important subject, and I am glad that it is being debated. I hope that, even with all the other difficulties that the health service is faced with, the Minister will take on board the vast experience in this Chamber on this subject.
When I was a non-executive director at King’s College Hospital NHS Foundation Trust, we were fortunate to have Cathy Warwick as the lead for maternity services. Directors were kept well informed about what was happening, but I understand from various CQC reports that that good practice does not exist.
I will cover items about the pay structure and about those who experience birth trauma of a severe kind—as well as a little about the deterioration in maternity care; but that has been well covered, so I will reduce that section of my speech.
I believe that the NHS pay dispute was avoidable. The origins go back to the clumsy and arrogant stance taken by previous Health Secretaries. One Health Secretary took the junior doctors on some years ago and beat them. Ministerial memories may be short, but junior doctors have longer memories. Whether they are badly led or well led does not matter; the strength of feeling is still there.
I will refer to the Government’s consultation on creating a new pay scale for nurses and midwives. Having had experience of this, I would caution the Government against any separation for a number of reasons. The Agenda for Change pay structure, carefully negotiated over a long period of time, is underpinned by the NHS job evaluation scheme, which determines the levels at which all healthcare professionals are paid. A separation of the nurses’ pay structure would divide and rule, which is irresponsible in the long term. It would not lead to more money or more midwives, it would not help with the chronic retention problem and, most importantly, it will lead to equal pay claims and a serious risk of unplanned extra costs.
My Lords, I declare my interests as set out in the register, in particular that I am the CEO of the Muslim Women’s Network UK. In that role, I published a maternity report, Invisible: Maternity Experiences of Muslim Women from Racialised Minority Communities, in 2022. I thank the noble Baroness, Lady Taylor of Bolton, for securing this important debate because, despite the many research reports and inquiries that we have had, we are still waiting for a step change in the improvement of maternity care. I will focus my comments mostly on maternity disparities for minority-ethnic women, data training and accountability.
Data is crucial to really understand inequalities. However, when maternity data is often broken down by ethnicity, it is usually done so into broad groups such as black, Asian and white, which masks the inequalities among different subgroups; they then remain invisible and continue to have poor outcomes. For example, Arab women are rarely spoken about but the research that I conducted found that they have poor outcomes compared with other minority-ethnic groups. In the south Asian group, Bangladeshi women tend to have the poorest outcomes. Among black women, I found that black African women and mixed-race women tend to have the poorest outcomes.
I also have concerns about poor outcomes for women from, for example, eastern European backgrounds, so it is also important to break down the white group further. In this group, women with lower educational levels, single mothers and very young mothers—in other words, women who have less of a voice—are also likely to have poorer outcomes. Can the Minister say when the Government will have a detailed strategy that responds to the inequality experienced by each group?
One way of responding to inequalities more quickly rather than just waiting for datasets, which can take time to produce and analyse, is to use feedback from the complaints system. However, research—even hospital complaints data—often shows that there is a low level of complaints from particular groups, certainly minority-ethnic ones. Can the Minister say what action the Government are taking to ensure that families are aware of the complaints procedures? How will they have confidence in that service?
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I was fortunate to be part of a team of professionals—midwives, obstetricians, anaesthetists, neonatologists and others—who were all committed to providing the best possible personalised care to all mothers and their babies. We never lost a mother in three decades, and had zero tolerance to intrapartum stillbirths. Weekly perinatal meetings were mandatory for all to attend to make sure that adverse events were fully discussed, learned from and never repeated.
The Government believe, as was noted by the noble Baroness, Lady Cumberlege, that the NHS is one of the safest places in the world to give birth. Minister, it was. In the past, our maternity services were where others came to learn. Why were our maternity units regarded as the best? It was because, as now, dedicated professionals provided safe, compassionate care to mothers and their babies, and took pride in doing so; and, importantly, they were left alone to get on with it.
Multiple reports from the CQC, as has already been mentioned, and independent investigations into several maternity units in England have shown that care is not safe, resulting in unacceptably high levels of harm to mothers and their babies. We all know that there are more such reports to come. While workforce shortages, pressures of work, lack of communication, and poor governance are all cited as possible problems, and they undoubtably are and need to be addressed, I believe that the genesis of the long-standing problems is deeper and goes further back. Therefore, I support absolutely the plea made by the noble Baroness, Lady Cumberlege, for a new beginning for maternity services.
The response from the Government and organisations responsible for the delivery of maternity services to adverse reports is to produce more documents about what they will do—set up a task force, a workforce plan that may deliver in five or 10 years, safety organisations, three-year plans, long-term plans, and much more. These lack implementation plans or regular outputs to demonstrate success.
The quality of maternity services is a bellwether for the quality of services in the rest of the NHS. Levels of maternal and perinatal deaths are good indicators of the quality of maternity services, as evidenced by several of the investigations. In this respect, as has already been mentioned, the latest maternal mortality report is a cause for concern in many ways. Confidential inquiries into maternal deaths were formally established in 1954, although their predecessor existed from 1928: it is the world’s longest-running successful audit system of healthcare and is a good barometer of the performance of the maternity service.
As has been mentioned, the latest report from MBRRACE of deaths between January 2020 and December 2022 shows that the rate of maternal deaths was 13.41 deaths per 100,000 maternities. That is the highest in the last two decades and much higher than the rate of 8.79 among the 2017-2019 cohort. Even after removing deaths due to Covid-19, the rate is significantly higher than among that cohort. The UK now has one of the highest maternal mortality rates in the developed world, compared with Norway’s 2.79, Germany’s 4.0—which, by the way, has remained static for 20 years—and France’s 6.0. We are way behind.
The main causes are important. The first is thromboembolic disease. We require a clear strategy for how we are going to reduce this, because it has remained the number one cause now for decades. I urge the professionals—the Royal College of Midwives and the general practitioners, obstetricians and psychiatrists—to come together to produce clear guidelines on how these deaths will be reduced. The second is cardiac disease. These deaths are preventable. Third, importantly and very tragically, are suicide deaths. These are vulnerable women whose mental health condition is not difficult to recognise during the antenatal period. They are women who might be abused in the house; women who are further abused when they take home a baby. We should not, as a society or as professionals, fail them, but we do. These 39 suicide deaths are tragic deaths: all maternal deaths are tragic, but these are particularly so. They are preventable and we should address that.
Maternal deaths also show up gross inequalities related to ethnicity and deprivation, as has already been mentioned several times. Black mothers have four times the risk, Asian mothers have twice the risk and mothers from deprived populations have twice the risk. These are not new or surprise findings, as mentioned by the noble Baroness, Lady Taylor of Bolton: inequalities in care and outcomes have been well documented for a long time. The Government have produced plans to try to reduce these, but none has shown any results. Can the Minister say which of the plethora of initiatives to reduce harm, deaths and inequalities in maternal health have had any effect? What benefits have been derived from the work of the Maternity Inequalities Oversight Forum, the Maternity and Neonatal Care National Oversight Group, the Maternity Disparities Taskforce, or the several other initiatives, in reducing inequalities and the deaths of mothers and babies and improving maternity services?
What we do have are repeated reports of high-profile organisational failures, soaring clinical negligence claims, huge variations in outcomes and in the culture of care, workforce challenges, inequalities in care and outcomes linked to ethnicity and depravation, rising maternal and perinatal deaths, and serious safety issues, to the point that the regulator, the CQC, says that England’s maternity units currently have the poorest safety ratings of any hospital services it inspects. Does this not all add up to a service that needs radical reform? Is it not time we had a root-and-branch independent review of maternity services that brings about the changes needed to have a world-class service that is compassionate, safe and delivers world-leading outcomes for mothers and babies? Can the Minister say why we should not have such a review, as part of his answer as to what difference all the initiatives so far have made to improve the service, with real figures to demonstrate it? I know he is fond of data as evidence.
I know well the chief executive of the Maternal Mental Health Alliance, because I worked with her in a charity that I chaired before she took up this role. I have heard from her over the past two to three years about the challenges in this area. I thank her team for their work and their briefing, from which I have benefited over many months rather than just for this debate. They are now working much more on the inequalities highlighted by most speakers today. In the Public Services Committee, we looked at what Covid revealed about our public services. It was absolutely clear that virtually none of them had understood the depth of the inequalities in how they responded to different racial and ethnic groups in our society.
We still have not got hold of what we need to do there. As the Minister knows, I have been anxious about this in terms of our preparation and trials of vaccines and how far they include ethnic minorities, because there are different genetic and cultural needs. Unless the workforce is sensitive and knowledgeable about that—practitioners must be enabled to be aware of it through their education and training, so that they can be sensitive to it when they are working with women from different cultural or ethnic backgrounds from their own—inequalities will be virtually inevitable. The Government have not been significantly sensitive to that in their approach, and that really concerns me.
Others have mentioned the stark reports from Embrace UK, which talk about not just the numbers but the effect on the women of their experiences. Others have talked about the numbers so I will keep my bit short, but, in looking at the care of black and white women whose babies have died, Embrace UK says:
“In around 1 in 2 baby deaths, the care assessed was poor. If care had been better it may have prevented the baby from dying … For around 3 in 5 mothers, care after their baby died was assessed as poor. If it had been better, it may have meant bereaved mothers were likely to have been better supported in their physical and emotional health”.
For both white women and black women—I will leave Asian mothers to the noble Baroness, Lady Gohir, as I am sure she will speak about them—the report assessed their care as good in only around one in five of the deaths reviewed. This is about basic care, not necessarily medical knowledge. Honestly, I am ashamed that we cannot do better and support our workforce so that it does better. Those disparities are huge.
On attitudes, another charity, Five X More, identified that the use of offensive and racially discriminatory language and being dismissive of their concerns was too often the experience of black, Asian and minority-ethnic women. Significantly, there was also a poor understanding of the anatomy and physiology of black women and of the clinical presentation of conditions in babies of black women. Then there were the racially based assumptions about the pain tolerance, education levels and relational status of black women. These are all issues in the basic care and attitudes experienced.
Most shockingly, mental ill health is the most common complication of pregnancy in the UK. At least one in five women experiences a mental health problem during pregnancy and after birth, and suicide is the leading cause of maternal death in the post-natal period. Again, this is honestly shocking. We need to be able to intervene much more appropriately. Midwives are ideally placed to ask sensitively about mental health in their routine contacts with women, but too often that simply does not happen.
Again, I come back to the fact that this is the time in women’s lives when they will have the most interactions with healthcare professionals, so it is the time to make sure that mental health becomes a normal way of working with women when they present to healthcare professionals—I do not see pregnancy as an illness—in whatever sense. Attention to mental health must be part of how they are handled.
I am really trying to say that there are lots of things that we know the Government must do. They need to get on and do them rather than continually doing reviews. Here I disagree with some other speakers; we need to get on and improve the services in the way that so many of us have been told they need improving.
Midwives are now men and women, and we do not seem to have recognised that in some of our structures in multidisciplinary teams. With men, we hoped that it would improve the provision of employment for midwives, as well as double the amount of people from whom we could recruit the pool. That does not actually seem to be working as well as we might have hoped.
Quite frankly, most multidisciplinary teams face large, unmanageable caseloads, and have to work with what—in some areas—are unsafe staffing ratios. To my mind, they often do not receive fair compensation for their important work. As commended by the CQC 2023 report, midwives and staff on maternity wards go above and beyond, when possible, to provide the best care.
However, services are being pushed to breaking point. As has already been acknowledged, it is estimated by the Royal College of Midwives that we have 2,500 full-time vacancies. This obviously leads to overload and understaffing in some areas, and the quality of care provided is put under threat. This is recognised in the 2023 NHS England Three Year Delivery Plan for Maternity and Neonatal Services, which highlights that supporting the workforce to develop skills and extra capacity is vital to providing future high-quality care.
I want to put this in context. When I went off to do mental health nursing as a second qualification, I was paid as a staff nurse. Now, it is almost impossible to get a second qualification without going back on a bursary. I will leave that for people to think about. I therefore support the commitments that have been made to ensure that trusts will meet staffing levels and achieve full rates for midwifery by 2027-28. However, it remains very difficult for a registered nurse to do a shortened course to become a midwife. I therefore suggest that women will continue to face what some do now: hurried care with staff having little time to provide truly person-centred support.
Like many other contributors to today’s debate, I have my own children and know that good health during pregnancy and labour and postnatally is vital. So is good healthcare. If you do not start with good health and then have poor healthcare, that is a pretty difficult situation. Staff need time to listen to mothers and fathers and to act when concerns are identified. As I have told this House before, with my first child, I felt ill. My husband came to visit me in the hospital the day she was born. I do not remember this, but apparently I grabbed his hand and said, “You will look after this baby if I die?” Then he realised he should go and talk to somebody, because this was not the way I normally talked about things. I had fantastic, fast intervention and had my baby within half an hour—who I am pleased to tell you is now a taxpayer. That was a good, cost-effective solution, but too often people do not listen to significant others, who sometimes understand very well what mothers are saying. We therefore cannot rest the whole responsibility on the mother in a time of distress.
It is necessary to think seriously about access to interpreters on a 24-hour rota system, so that women who are unable to speak or understand English because it is not their first language can be assisted in communicating with the staff caring for them. We have situations in some areas in which it is impossible to get an interpreter. That makes the situation really difficult, both for the midwives and for the mother. One cannot always rely ad hoc on a relation interpreting what is really going on. Can the Minister comment on how access to interpreters is monitored within the NHS and, if this is not being undertaken, can he ask the Government to make provision to do so? I have been informed that this is particularly important in genetic counselling in families from cultures that are different from those of the midwives involved.
Staff are often unhappy due to pressure at work, in part associated with low levels of staffing. As other noble Lords have said, it is also because senior midwives are retiring or retiring earlier than planned, for a variety of reasons. Many who are leaving are specialist mid-career midwives, whose skill set cannot be easily replaced, particularly in terms of supervising student midwives. I am really proud that the daughter who is the taxpayer is a teacher. However, teachers get rewarded on top of their salaries for supporting student teachers if they are the lead in it. This is an example of something we could learn from.
In part, retention issues reportedly stem from inflexible working practices. Flexible working is difficult to manage in a 24-hour, seven-day service. I know; I have tried it. However, some trusts have much better retention than others. How can best practice be shared and replicated to retain midwives across the NHS services?
The stress of unmanageable expectations at work is creating burnout, as some others have reported, and encouraging some midwives to leave the profession. Perhaps we should think about a structure for sabbaticals for some midwives. Midwifery is, at the best of times, hard physical and emotional labour. We do not always recognise that. When things go well you get the rewards but, as my noble friend Lord Patel has just spoken about, when things go badly it can be devastating.
Capacity is being undermined by a lack of investment in continual staff development. This is highly worrying because, as others have said, we face an increase in complex births, as more women are giving birth over the age of 35—as I did—maternal diabetes has increased, the use of induction and caesarean has increased, and pre-term births are becoming more common. These cases require specialist skills so that mothers and babies are safe. However, a lack of training and development opportunities for midwives, both men and women, can lead to a deficit of skills that are vitally needed for our specialist services to survive in the future. Midwives need to be skilled at recognising complications in pregnancy, ensuring that they pass those to other members of the multidisciplinary team for assessment, so that, wherever possible, early intervention can be undertaken.
The vast majority of our student midwives in England report having to take on additional debt, over and above the loans available to students, to cover their basic costs. This is undoubtedly putting people off coming into midwifery. The National Union of Students reported a worrying drop in applications to university courses, from 13,500 in 2021 to just over 10,000 in 2023. Can the Minister say whether the Government will consider the NHS undertaking loan repayments for university fees after, say, three or five years of NHS service? It would aid the retention of midwives, nurses and indeed junior doctors, as well as other professions allied to medicine.
Our midwives work tirelessly to provide the best care they can, but they are often unable to do so because of the issues highlighted by other noble Lords and in my own contribution. We must ensure that these issues are tackled, so that every woman is provided with truly person-centred, skilled and compassionate care, and that all babies have the best possible start. The Royal College of Nursing has produced nursing workforce standards that could apply to paediatric intensive care units. Similarly, the Royal College of Midwives has provided evidence on the necessary ratios of midwives to expectant mothers at differing stages of pregnancy. Are this Government prepared to consider legislation on workforce standards in the NHS in future?
That is not a theoretical view. When I first arrived at ACAS, I was faced with over 500 equal pay claims from ACAS staff. It caused a great deal of amusement from my previous TUC General Council colleagues when they heard I got the job of chair. This was in the days of a Labour Government, so I am not making a party-political point on the subject of pay structures. The problem arose because of the break-up of the Civil Service negotiating structure and the separation of grading by government departments and non-departmental public bodies. ACAS, as an organisation, given the problem of 500 equal pay claims, was faced with sclerosis and low staff morale and risked being a laughing stock, because it was supposed to solve employment relations problems, not be the centre of them.
It was clearly a priority for the ACAS council and the new chief executive to solve. I will not go into the details of how it was done—why give away trade secrets?—but it cost us £10 million. We were given the money by government, but exactly the same amount was taken off us the following year. Subsequent redundancies cost us hundreds of staff and thousands of years of experience. Compared with the number of nurses and midwives, that cost is small beer. I urge the Government to think very carefully before they leave such chaos behind.
The Minister will no doubt be aware of the All-Party Parliamentary Group on Birth Trauma and its recent launch of a parliamentary inquiry on birth trauma. It is co-chaired by Rosie Duffield MP and Theo Clarke MP, and will be assisted by the charity Birth Trauma Association. Its stated aim is to collect evidence so that government can take practical and achievable steps to improve care and support for new mothers and their partners, and incorporate birth trauma into the women’s health strategy. The stories told by some women of their experience are horrifying, and the physical and mental trauma suffered by some are often unrecognised by the very professionals who should know better.
A relative of mine gave birth to two children and the effect on her was shattering. Her mental health did not recover for two decades. She spent months in a mental health institution after each birth. This might have happened under any circumstances, but recognition of the dangers, and the right information and preparation, might have led to a different outcome.
Recent CQC inspections reveal that maternity units are failing women; the figures have already been stated. According to the Birth Trauma Association, some women who have had a dreadful experience find that they are not listened to. They say that complaints are met with attempts to minimise the women’s trauma and deny responsibility. Frequently, the BTA was the first organisation to listen to women’s accounts and acknowledge their trauma.
A common feature is the failure to acknowledge pain levels. In a recent television drama series, two of the regular male doctor characters were challenged to take a test to experience similar levels of pain to those experienced by women in childbirth. The test went from “mild” to “severe”, and they were only half way up the painometer before they pleaded for it to stop. I know that it was a drama—although we have learned how powerful dramas can be, in different circumstances—but it clearly illustrated a point that women have been making for centuries. I should add: please do not try this at home. Will the Minister ensure that his department studies the results of the APPG inquiry when it is published and take steps to improve things?
Finally, the CQC’s 2022 maternity survey, designed to assess the quality and safety of maternity services in England, received over 20,000 responses. They showed that experiences of maternity care have, as has been said, deteriorated, particularly over the last five years. The issues of availability of staff, confidence and trust, and communications and interactions with staff have already been outlined.
I should emphasise, as did the noble Baroness, Lady Cumberlege, that the majority of respondents were satisfied, but sometimes it is now a very narrow majority. For instance, in-hospital care after birth showed that a worrying 57% of respondents said they were always able to get help, while, as my noble friend Lady Warwick said—she has already mentioned the shortage of 2,500 midwives—the Royal College of Midwives has described the impact of staff shortages on women as “stark and sobering”.
Up to now, the Government have said that they have no plans to commission a public inquiry into the future of maternity services, despite the fact that it has been suggested by the Maternity Safety Alliance and Mumsnet. Can the Minister say in what circumstances the Government would change their mind about a public inquiry?
Given the poor experiences of minority-ethnic women, one would expect them to be overrepresented in maternity litigation data, which would help to indicate where the risks are for them. If they are underrepresented, it would indicate that they are not being compensated for the harms that are being caused to them. I decided to investigate this issue during my research so I put in a freedom of information request to NHS Resolution, the body that deals with claims of compensation on behalf of NHS England and which apparently works to resolve concerns and share learning and improvement. I was shocked to receive the following response in 2021:
“In terms of ethnicity breakdown, this information is not held as it is not recorded in our claims management system”.
This was astonishing given that ethnicity data is routinely collected by the NHS and is crucial for identifying inequalities between different groups. This is perhaps one of the clearest examples of systemic discrimination by the NHS.
I have since had letter exchanges with the CEO of NHS Resolution and asked for ethnicity data to be recorded. The response has been positive: I have been told that the data management systems are being upgraded now to record all protected characteristics. I have been informed that it may be a voluntary option, however, which is likely to result in low data capture. Yet this data can be pulled in from hospital records; it is routinely collected. I have also been informed that data and trends will be shared only internally for learning, so how will the public identify trends and hold the NHS to account?
I ask for assurances from the Minister. Will he ensure that NHS Resolution collects protected characteristic data from the hospital management systems, rather than on a voluntary basis, and that this information is made available to the public? This would help identify inequality among different groups for all types of medical negligence claims, not just maternity claims.
Next, on training, although workforce shortages will no doubt contribute to poor healthcare staff attitudes and poor maternity care, many maternity research report findings provide clear evidence that there exists among some midwives and obstetricians a culture of being desensitised to women’s pain and of having negative attitudes towards women, which is even more pronounced for women from racialised minority communities. How do the Government plan to address the issue of patient engagement and cultural competency training? Having served on a hospital board, I know that, if a maternity ward is short-staffed, staff will not have the time to undergo such training. Also, the UK has large numbers of doctors and nurses recruited from abroad. Their culture of patient care is likely to be different. Here I refer to non-medical aspects of patient care. Does the Minister agree that some kind of approved patient communication training should be mandatory for recruits from abroad?
Finally, have the Government pulled together the many recommendations made by numerous maternity reports, such as those from Birthrights and Five X More—including the one that I authored—to ensure that the recommendations are being implemented? The Government’s women’s health strategy does not adequately deal with many health inequalities for women—minority-ethnic women in particular—including maternity disparities. More needs to be done there; the strategy needs to be strengthened. I therefore urge the Government to appoint an independent maternity commissioner from outside the NHS to provide scrutiny and hold all agencies to account, which would benefit all women. We have commissioners for many other areas. In maternity services, too many babies and mothers are dying or ending up with poor outcomes, which can have lifelong consequences. Will the Minister agree to the appointment of a maternity commissioner?
Many factors have been highlighted by the CQC. Staffing shortages—especially retention issues, which I will come back to in a minute—are top of the list but it has also reported systematic racism, leadership issues, and workplace and environment issues. All of these are significant and each needs attention but we should not lose sight of the overall situation and the fact that nearly half of these units are causing concern. In those circumstances, we need to stop and think about what needs doing—and doing urgently. I know that there has been considerable ministerial churn and that current occupants may try to distance themselves from previous decisions. Although new Ministers must say that there should be greater emphasis on women’s health, et cetera, the same party has been in government for 13 years and decisions taken during those 13 years have made the situation worse. I think that Ministers in that Government are culpable.
To my mind, the most significant problem is clearly the shortfall in staffing, in particular the imbalance in the workforce because of retention problems. The fact is that many senior midwives, gynaecologists and obstetricians are leaving their professions. There are concerns about the number of students going into midwifery and their experience but the problems of retention make the situation critical.
Earlier this month, the BBC reported on midwives being concerned that staff shortages were causing safety issues. One midwife reported that she kept patients safe only by the skin of her teeth; another said that she had quit because she could not face the possibility of the consequences of poor care. I know of one experienced midwife who left her chosen profession after being in sole charge of six women in labour and being afraid for her own mental health because of all the pressures that that responsibility brought.
The Royal College of Midwives says that staffing is the most important issue. We hear that some trusts have one in five jobs unfilled. In Kirklees, the figure is 18%, but it is not a matter of just getting more students into midwifery. Retention is a serious problem and burnout is a real issue. If we cannot retain experienced midwives, we cannot give student midwives the support and the mentoring that they need during placements.
There have been some suggestions that existing midwives feel threatened by some of the training changes that were introduced a few years ago, and there is always a question about the balance between theory and practice. Certainly, the profile of students in midwifery and nursing generally has changed. I know from my time as chair of the University of Bradford, which has a fantastic department in this respect—maybe the Minister would like to visit—that the profile of students coming into nursing has changed significantly, especially when bursaries were cut by this Government. The intake of mature students declined sharply and immediately, and it has not fully recovered. It has been pointed out to me that having mature students among the student group helps everyone to develop and understand what all the pressures can be. Of course, many students are feeling the cost of living crisis and want to work to survive financially, which is obviously not easy if you are on a midwifery course. I worry about the figures for those dropping out of their courses in the early years.
One factor that particularly worries me is that I am told that there is less continuity of supervision of students on the ward during placement. Each student used to have one named mentor, but I am told that this is no longer the case and that students therefore report that they no longer feel part of a team or that they belong, and that this was also affecting the drop-out rate. Overall, this is a worrying picture. Unless the Government address the retention issue, we will not make the substantial improvements that we need.
I must also talk about maternal mortality. The latest report shows that it has risen to its highest rate in 20 years. A key finding is that the maternal death rate for black women is three times higher than that for white women; for women from Asian ethnic backgrounds, it is two times higher; unsurprisingly, women living in the most deprived areas have a maternal mortality rate twice as high as that for the least deprived. This is not a revelation; other reports have talked about it for a long time. There is no excuse for a lack of action here. I note that the Select Committee in the Commons pointed out that, at the time it was writing its report, the Maternity Disparities Taskforce had not met for nine months. That cannot be acceptable and shows a worrying level of complacency.
I have outlined a very depressing situation, and urgent action is needed. Midwives and others deserve credit and recognition for the work that they do—my noble friend Lady Thornton will tell us about the remarkable achievements in her area of dealing with the consequences of female genital mutilation, and I know from a colleague in the other House, Jess Phillips, that midwives are often critical in helping women escape from abuse—but, overall, we have a crisis. For such a significant service as maternity, in 2024 this is unacceptable. It is up to the Government to provide a proper lead to solve this. I emphasise again that the No.1 priority must be the retention of experienced nurses and midwives. We need a raft of measures to reduce the pressure on midwives and allow them to feel that they can do the job that they are trained to do and want to do to the level that they want to achieve. If the retention issue is not tackled urgently, there will be no space to deal with all the other issues such as updating training. This is all against a general backdrop of serious health inequalities which exist in this country anyway.
We are now in 2024. It is just wrong that maternity services are causing such concern. Every woman deserves the best while pregnant and during childbirth, and every midwife deserves the right conditions in which to work. The Minister said at Question Time earlier that he believed in evidence and common sense. I urge him to attach that common sense to the some of these problems that we are facing this year.
What we heard guided us, and the five-year plan we set out was based on what women told us they particularly wanted. At the core were two things that we believed would raise the quality of care and improve safety, leading to better births. The first was that women wanted, and felt they needed, the same midwife, or small team of midwives, throughout the maternity journey. They wanted a relationship based on trust and mutual respect. They wanted a midwife, or midwives, who knew them, understood them, and respected their birth plans and the choices they were making. We call that continuity of carer.
The noble Baroness, Lady Taylor, has raised this afternoon the issue of continuity. We know that continuity leads to safer care and better outcomes for the mum and the baby. Yes, continuity may be challenging in the face of workforce pressures, but we need to be much clearer that continuity is the model of care that we want to see. I think that that is what the noble Baroness was stressing, and I support that.
Secondly, women and their partners want to feel and know that their continuity of care is shared, around them and by them. We call that “personalised care”. It is centred on the woman and her baby, based around their needs and decisions, and where they have genuine choice—informed choice, but with unbiased information. Too often care is done to women and babies, rather than chosen and shaped with and by them. I know that, when staff are under huge pressure, taking the time to understand a woman’s choices and build care around her may be really very difficult, but that is what we should strive for, for all women.
Continuity and personalised care were at the heart of the five-year strategy. They stand at the heart of turning the phrase “better births” into reality. Today’s reality falls short on both continuity and personalised care. Our country is still one of the safest in which to give birth—I want to stress that—and we have met some of those wonderful staff who run our maternity services. But the evidence tells us that we are not achieving the progress that we could and should.
The most recent MBRRACE report on maternal mortality tells us that 293 women died in pregnancy or within 42 days of the end of pregnancy in the three years between 2020 and 2022. That is a significant increase over the previous years, and it excludes Covid-related deaths.
The CQC Maternity Survey 2022 tells us that 10% of maternity services are inadequate and that 39% require improvement. I was delighted that the noble Baroness, Lady Taylor, mentioned the work of the CQC, which is so important, but the figure of 10% of maternity services that are inadequate and 39% that require improvement accounts for nearly half of all services. The CQC says that safety and leadership are particular areas of concern, and they need to be addressed. We are all sadly familiar with the series of local failings in maternity care and the inquiries that have followed. I am thinking of Morecambe Bay, Shrewsbury and Telford, East Kent and Nottingham; those are just examples. Parents who have been involved in those inquiries are now calling for a full national inquiry, and I think they are right.
My Better Births report was published in 2016 and had a five-year plan, but those years have now passed. I believe that we need a fresh strategic national inquiry and a new coherent and practical plan for the whole maternity system. We need to tackle the issues of poor quality and poor outcomes. We need to listen to women and their families, and the staff who are there to care for them, and we need to be guided by what the evidence tells us will lead to better births, to make them safer and as a good an experience as is possible.
Finally, I would like to repeat something from the letter I wrote to the women of England at the start of the Better Births report in 2016:
“The birth of a child should be a wonderful, life-changing time for a mother and her whole family. It is a time of new beginnings, of fresh hopes and new dreams, of change and opportunity. It is a time when the experiences we have can shape our lives and those of our babies and families forever. These moments are so precious, and so important. It is the privilege of the NHS and healthcare professionals to care for women, babies and their families at these formative times”.
I hope those words might play a part in setting the tone and direction for what I believe is now needed: a fresh plan for maternity care.
The “stark and sobering” truth is that, in recent years, our maternity services have got worse, not better. The Care Quality Commission’s latest maternity survey shows the decline in positive maternity experiences. Confidence and trust in staff delivering care, whether antenatal, in-hospital or postnatal, has fallen over the past five years. Staff availability, and communications and interactions with staff, require improvement. My noble friend highlighted the BBC report from last November, which analysed CQC data and found that 67% of England’s maternity units—more than two thirds—had been rated by the CQC as inadequate or requiring improvement, up from 55% in the previous year. The CQC describes the overall picture as
“one of a service and staff under huge pressure”.
That is a thunderclap of a warning from the regulator.
More recently, we have data showing that the maternal mortality rate in the UK has risen to levels not seen for a decade, and shocking inequalities are contained within these figures. An investigation led by Oxford Population Health found that the maternal death rate was three times higher for black women than for white women, and two times higher for women from Asian ethnic backgrounds. Women living in the most deprived areas had a maternal mortality rate more than twice as high as those living in the least deprived areas.
Alongside the disturbing national data, we have seen catastrophic failings by specific NHS maternity units across England. The independent review of maternity services at the Nottingham University Hospitals NHS Trust is ongoing, while the investigations into maternity care at University Hospitals of Morecambe Bay NHS Foundation Trust, the Shrewsbury and Telford Hospital NHS Trust and the East Kent Hospitals University NHS Foundation Trust all produced recommendations for action, all prompting new oversight groups, strategies and targets.
We now have a national maternity safety ambition to halve the 2010 rates of stillbirths and neonatal and maternal deaths by 2025, which I understand we are not on target to achieve. Can the Minister confirm that? We have a women’s health strategy and the NHS long-term plan—and we finally have a Three Year Delivery Plan for Maternity and Neonatal Services, published in March last year. It sets out how the NHS will make maternity and neonatal care
“safer, more personalised, and more equitable”
for women, babies and families. This is a great ambition—an essential ambition—but where are the building blocks that are needed to achieve it and overcome the stark data I quoted earlier? It seems to me that we have some way to go for this ambition to become a reality.
Midwives who shared their experiences ahead of this debate tell me that they have lost patience with reports and reviews. They say it really is about the numbers: more midwives in the wards means better care for mothers and babies, fewer mistakes, a more positive and supportive culture for midwives to work in and more reasons to stay in the profession. “Invest in more staff as quickly as possible” is the message I received. As we have seen from some of the terrible failings in recent years, ensuring a culture that fosters openness and learning really matters. I was dismayed to find that a number of midwives were not prepared to talk to me because of the negative repercussions for colleagues who had previously spoken out. Donna Ockenden’s review of Shrewsbury and Telford Hospital NHS Trust maternity services, published in March 2022, puts it succinctly:
“Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe, and compassionate, maternity care locally and across England”.
I therefore ask the Minister: can he give us any new update on progress on the actions and recommendations in the NHS England Three Year Delivery Plan for Maternity and Neonatal Services? How are they ensuring that recommendations for action will be widely implemented in all maternity services across England? We need to know that we are moving forward. We must do better, and we must do so quickly.