UK Parliament Health and Social Care Committee Formal meeting (oral evidence session): Enquiry - Safety of maternity services in England

December 15 2020 
 
The session began with Tinuke from the FiveXMore campaign giving an outline of the campaign and sharing birth stories including her own that exemplifies why birthing people are left feeling unimportant, unheard and that their pain during the birthing period was not taken seriously. 
 
When asked on what could be done to change the disparities and prevent future harm Tinuke and Clo from the FiveXMore campaign named the following actions: 
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1. More NHS investment into addressing these issues 
2. Research that includes black women experts as part of the research team and more consideration of the lived experiences of those affected by the disparity.
3. Data collection on near misses, morbidity and illnesses and poor outcomes  
4. The NHS must commit to a target to close the disparity gap 
5. Black women need to be given information to make informed choices in relation to their care 
6. The word BAME should be minimally used in maternity services to ensure that it is clear who is being referenced.   

Professor Knight (Professor of Maternal and Child Population Health at the University of Oxford) agreed that there is a particular issue underlying maternal deaths with pregnant people presenting on multiple occasions and not being heard. Specific research was carried out looking at the care received by women from different ethnic groups. The results from her research suggested that there was no differences in care when comparing ethnic groups. However, there was evidence to suggest that approximately 40% of women might not have died if they had received different care.  
 
The research also concluded that there were 17 clear biases in the care received. The 3 leading biases found were: 
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1. “Not like me” This bias was most prominent when people were caring for black women. There was less nuanced, individualised care and poorer listening skills employed when people attended to black women. 
2. Complexity - Clinical, Social and Cultural The highest number of women who died were those with complex care needs and multiple complications. The research found evidence of structural biases resulting in inadequate care. This theme was an issue for women in all racial categories.
3. Micro-Aggression This bias was particularly found in the care of Asian women. Racial stereotypes were seen to be a contributing factor to these micro-aggressions in particular with women who do not speak English fluently. “Agitation was assumed to be due to mental health problems when they were actually seriously physically ill”. Specifically, the micro-aggression of using family members to interpret meant that there was less likelihood of some important personal information affecting the pregnancy being conveyed to health workers due to lack of privacy. 

​Professor Knight confirmed that the disparity in maternal mortality rates between black and white women has been getting wider.  
 
Tinuke shared some of the results from FiveXMore’s consultation with 400 Black women. Of those women: 
 

• 78% Did not receive advice/guidance on how to make an informed decision on home births 
• 70% Did not receive advice/guidance on how to make an informed decision on water births 
• 73% Were not presented caesarean sections as an option 
• 85% Were not given advice on having an assisted birth  
• 94% Were unaware of the Health and Safety Investigation Branch (HSIB) and were unaware of how to make a complaint when they had bad experiences during their pregnancy and childbirth, even when they were at risk of losing their life because of the negligent care that they had received. 

• Of those that engaged with HSIB to raise a concern 74% did not receive a follow-up. 

 
Professor Jenny Kurinczuk, (Professor of Perinatal Epidemiology and Director of the National Perinatal Epidemiology Unit, at Oxford) Shared that whilst overall perinatal mortality has fallen from 2015, there is a racial disparity in stillbirths and neonatal deaths. There is a twofold increase for black babies and a 60% increase for Asian babies. This particular disparity appears to have slightly increased over time. There is still no explanation for the disparity although some might be accounted for by the variance in acceptability and uptake of termination of pregnancy due to a congenital anomaly and also deprivation. Further research is required. 
 
She confirmed that the MBRRACE research shows that there is twofold difference in maternal mortality for the most deprived parents and that there are a lot of factors that are interlinked. There is still work to be done to understand the individual risk factors in a number of the issues.  

Ethnicity does not create a variation in cause of mortality, almost all of the women who died had pre-existing mental health or medical co-morbidities. However, pregnant person bias does exist. The leading cause of maternal death is heart disease, the symptoms associated with heart disease (central chest pain, breathlessness and pain going down the arm) are sometimes overlooked as a symptom of pregnancy and therefore at times missed by medical staff in acute care settings or by junior or less experienced staff. 
 
Professor Kurinczuk confirmed that the MBRRACE team is conducting a confidential inquiry into the deaths of babies to black and black British mothers. This inquiry began at the beginning of 2021. 
 
Maternal Mental health and Suicide  
The data suggests that race is not a contributing factor when looking at risk of maternal suicide, however there is a bias that normalises or dismisses symptoms of parents who are vulnerable to suicide therefore preventing intervention and support. Another issue is that the majority of women who died in this way sought help on multiple occasions but our current care systems are not holistic enough to give visibility to concerning patterns. MBRRACE urge that repeated presentations should be viewed as a red flag and an emphasis should be placed on making diagnosis not just excluding them. 
 
Continuity of Carer 
The consensus from both Professor Knight and Tinuke was that continuity of carer would work in cases where the right team with the right expertise to provide individualised care were put in place to support women, particularly those with complex needs. 
 
Preliminary outcomes from the interim Ockenden Report 
Donna Ockenden shared that the overarching issue was a failure to listen to the families and also a culture of placing blame on the families when things did not go as they should have. 

• There was a culture of pressuring pregnant people to give birth vaginally and avoid c-sections, even when there was a contraindication to do so. The pressure was from both obstetricians and midwives.
• Women and pregnant people need to be listened to.
• Informed choice with regard to place and mode of birth should be based on accurate information and free from ideological bias. 

• Women and pregnant people with complex care needs should be under consultant oversight. 
• Antenatal consultations should be used as opportunities for continual risk assessment to understand which pregnant people are in need of specialist attention. 

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RCN Chief Executive Gill Walton confirmed that an approach that could be taken to address the national shortage in maternity the workforce is to specify the requirements necessary to support one safe birth and use that for guidance. Dr Edward Morris (president of the RCOG) agreed. 
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Both also agreed that maternity should have sound representation at the board level of NHS Trusts. There was consensus amongst both that whilst the HSIB provided good information to also meant that local opportunities to learn from mistakes were lost. 
 
Additional scans later in pregnancy 
Professor Gordon Smith from Cambridge University, spoke on the usefulness of a presentation scan at 36 weeks to help assess risk and provide information for informed choices to be made about location and mode of birth. He suggested that this would reduce the likelihood of emergency C-section if it is already determined that the baby is in breech or other presentation that may require additional support. 
 
How to use the data currently collated to create lasting change. 
There was agreement with Dr Morris and Gill Walton that there needs to be a more responsive data collation system that could potentially be anonymised and collect data from the CQC inspections, HSIB, NHSR, the NIS and all of the inquiries and reports that are ongoing with additional datapoints from the families. This could potentially also alert Trusts of cultural issues that need to be addressed. Dr Morris confirmed that an additional layer is not required but the data that is already collected must be used in a more systematised and timely fashion. We should hear about the near misses and feed all of this information into the governance system of the trusts so that they can learn and improve in a more responsive way. 
 
The damaging effect of using the term “normal birth” 
Both the heads of the RCN and RCOG were asked to commit to not promoting the use of the term “normal birth’ because of the impact it may have on families when considering the mode of birth that is safest for their particular needs. The potential for a hidden pressure to be exerted on families by the labelling of physiological birth as “normal” was identified by the committee. Both heads agreed that they would not encourage the use of this term. 
 
Source:https://committees.parliament.uk/event/3111/formal-meeting-oral-evidence-session/  
 
Written by Elizabeth Odunlami