Birth Companions’ response to the independent review of maternity services in Nottingham

Nobody expected this report to be an easy read. Like so many reports before it, the Ockendon Maternity Review’s latest findings are deeply distressing. It presents evidence of widespread, avoidable harm done to women and babies and their families. A foundational failure to listen. Accounts of women feeling dismissed, disempowered and blamed. Evidence of deeply ingrained systemic and interpersonal racism and bias, leading to poor outcomes for those already facing inequity and disadvantage.

Birth Companions’ thoughts are with every single one of the 2,500 families whose experiences are found in the pages of this week’s report.

Midwife, author, women’s health advocate and Birth Companions’ Ambassador, Leah Hazard, has commented on the findings:

This report once again confirms that the most vulnerable women are least likely to be heard and protected in our broken maternity system. I hope that this moment leads to a real reckoning and a transformation in the way maternity is managed and provided, right from upper management downt o the shop floor.

We see yet again in this report how race and deprivation shape who is at most risk of harm, and whose voices are heard. Nationally, as MBRRACE data cited in the report makes clear, Black women remain almost three times more likely to die during or after pregnancy than white women, and women in the most deprived areas twice as likely as those in the most affluent. The tragedies we have learned about in this report illustrate issues that exist across the country. They form part of a predictable pattern within a system that has not been designed or resourced to work for women facing complexity, inequality and disadvantage.

The report clearly shows that the trauma experienced by many women affected is rooted not only in what happened clinically, but in how theywere treated. That said, the failings in Nottingham, and those that feature inevery maternity investigation, are not only a result of a lack of care. They are the symptoms and failings of chronic under-resourcing, unsustainable rotas, insufficient supervision and cultures where trauma-informed care is absent, and raising a concern feels unsafe.

The report sets out eighteen immediate and essential actions for maternity services across England. We welcome this direction of travel, and note that several of these actions reflect what women and organisations like ours have long called for – for women to be listened to and their concernsacted on;  for women facing the greatest  inequalities, and the greatest barriers to safe care, to receive consistent, joined-up care; and for workforce planning to finally account for the realpressures staff are working under.

Recommendations require resourcing. The report documents a staffing crisis in forensic detail, but stops short of calling for the investment needed to address it. Ockenden and her team have done their part. Government must now do its job.