When Maternity Care Fails, We Often Blame The Wrong People

Recent independent national inquiries into maternity care in the UK have invited patients to submit accounts of their experiences via public self-reporting systems, and it is clear that mothers and families mostly blame the actions or inactions of frontline workers for their plight: midwives who did not listen or take their concerns seriously; staff who prejudged them or treated them differently; obstetricians, anesthetists and pediatricians who did not respond fast enough or even at all. 

The public are right to feel that they have been let down, but by focusing their anger solely on key individuals they have interacted with in healthcare settings, they are missing the wider problems. 

The most commonly used adjective to describe NHS services is “underfunded,” but this is simply an excuse that hides a much more sinister problem that no one has the appetite to address. Funding for maternity care has increased enormously over the last two decades, but the service continues to deteriorate. This is because NHS resources are not always mobilized to achieve the best clinical outcomes for patients. 

For many decades, the focus for maternity management teams has been to ensure value for money and adopt clinical safety strategies that placate healthcare commissioners and regulators. In practice, this means implementing processes which sound good in theory but absorb vast resources and prioritize back-office roles rather than frontline care.  This leads to fewer clinically active staff as most are siphoned off into managerial roles. It also leads to reduced capacity and micromanagement of a service in which the meager “left-over” resources that trickle down onto the shop floor are utilized as best as possible.  Unsurprisingly, this leaves many frontline staff frustrated and burnt out, feeling enslaved to a system of care which prioritizes targets and league tables over patient outcomes. Speaking up can have dangerous consequences, so silence prevails, and problems go on for longer. 

Given the state of the frontline service, it is unsurprising that many women turn to online sources for advice, information and guidance. These are inviting, friendly, and accessible 24/7, but the information they provide is frequently inaccurate and almost always fails to provide individualized guidance. Parent education classes and social narratives around birthing mostly focus on the so-called “low risk” birth. These are powerful, even coercive, but often set unachievable ideals. 

Patients often describe what should have happened yet seem able to dissociate this from the anti-intervention narratives they subscribed to prior to delivery. They do not always appreciate how stressful midwives find it to counter the directives laid out in a mother’s birth plan, or how much objection many mothers raise when presented with an alternative if complications arise. Staff are sensitive to accusations of fearmongering if they discuss risks or of dismissing maternal choice if they challenge requests. There is a natural tendency to listen more to what we want to hear and overlook what we think is irrelevant or unlikely. 

The net effect of the deficiencies and inefficiencies in care, and the misinformation and disinformation, is often a great deal of disappointment, anger or grief and calls for retribution. 

But who should be held accountable? 

The national screening committee who limited antenatal tests which might have alerted the mother to a problem? The management team who allocated funds to tick-boxing processes ahead of the CQC inspection rather than buying new equipment or employing more frontline staff for the unit? The Trust leadership team who promised that “lessons will be learned” following previous incidents? 

Or what about the antenatal class instructor who promised an empowering experience controlled perfectly by nature? The online birthing guru? The yoga teacher? The neighbor, best friend, or older sister? 

No, these people rarely become the target of ire because none of them were present providing direct care. The fact that they all played a pivotal role in creating the conditions in which care is delivered, or the ideology that set the mother up for failure, is overlooked. Only the frontline staff present in the room with the mother at the time of the crisis are held responsible. 

It is certainly true to say that poor maternity outcomes are often, but not always, avoidable. But to avoid them requires everyone to be on the same page and unafraid to speak out. Mothers have quite rightly been given the space to have their say. Their anger, whilst entirely justifiable, is often misdirected at the frontline staff who could undoubtedly do better in some cases but at present simply feel like the fall guys. If we are to have any hope that matters will improve, mothers and their relatives will need to look beyond their rage and dig much deeper to identify other key contributors to this complex problem and commit to tackling them.  

This article originally appeared on Your Coffee Break. Written by Dr. Lorin Lakasing.