When midwives are no longer trusted to deliver the goods

A 2012 report from the NHS Litigation Authority detailed the mistakes that occurred in 5,087 births in England between 2000 and 2010. It cited junior doctors and inexperienced midwives managing women’s labour without adequate assistance from senior clinicians. This was described as a “serious wake-up call” for urgent improvement. Yet still we hear horror stories, some utterly tragic, others of distressed women having to beg for a doctor or an epidural and being made to feel guilty if they don’t achieve a “natural” birth.

Speak to a cross-section of people ranging from midwives to trainers and a complex picture emerges. Some midwives feel overworked, others have to pay for their own update training or do it in their own time and others believe midwifery is better than it’s ever been. One midwife, speaking anonymously, was at pains to say that relations between doctors and midwives are mostly good and that mothers are in excellent hands.

However, where they are not it creates a toxic atmosphere that pervades the whole unit; she chose not to work in one particular London trust because many midwives there are known to be domineering and aggressive. Is that driven by a natural-birth agenda? “I don’t get the sense these midwives are particularly woman-centred — they’re just bolshie and aggressive,” the midwife says. “They’re potentially a bit older and entrenched in an ‘I’ve been doing this for 30 years and you’ve been a doctor for five minutes’ way. They’re almost fearless, whereas my generation very much trained with the idea that if you do muck up you’ll be held accountable.”

Heather Paterson’s experience of botched delivery at the hands of a grotesquely bullying midwife truly is the stuff of nightmares. She was two weeks overdue when admitted to the Royal Free Hospital in London in 2005. It was Easter weekend and doctors were thin on the ground. The midwife incorrectly gave her double the dose of a gel used to start labour then left her alone despite her being in pain. Yet things were to get much, much worse.

As time passed Paterson, who was then a BBC World Service journalist, screamed in agony for a doctor and pressed the emergency button three times but the midwife, Biobelemoye Toby, told her “no pain, no gain” and that she was a “silly girl” who did not deserve a baby. When Paterson asked for a caesarean she was told there was “no need”. She felt the inference was that she was “too posh to push”.

Paterson’s husband, Iain Croft, then also a BBC journalist, was so concerned at what he was seeing he began taking notes. Riley Arthur Croft was born the next morning with the umbilical cord wrapped around his neck. Despite resuscitation efforts he couldn’t be saved. Paterson says she was told: “Don’t worry: you can have another baby.”

An inquest jury ruled that Riley died of “natural causes to which neglect contributed”. At a subsequent Nursing and Midwifery Council disciplinary hearing Paterson described her treatment as “torture”. The hearing accepted that Toby, 71 at the time of the hearing, and another midwife had committed a series of blunders, most fatally failing to monitor the baby’s heartbeat. Toby was banned from practising but the second midwife was allowed to continue working under supervision.

Today the couple remain tortured by those horrific events (both were diagnosed as having post-traumatic stress disorder), but are also angry that tragedies such as those at Morecambe Bay continue to happen despite the mantra that “lessons will be learnt”.

They have now moved to Perth in Australia. When Paterson saw a gynaecologist there he was astonished that, as someone having her first baby at 41, she wasn’t offered a C-section automatically (Paterson says this is the case for most Australian women over 37). Paterson believes this is part of the problem: not anticipating the higher risks associated with older maternal age.

“The NHS has to wake up to the fact that women are having babies older now, so the old model, such as midwife-run birth units, aren’t suitable for older patients,” she says. “You have a system that is catering to a culture from 50 years ago and it hasn’t caught up with social changes.”

Although Paterson agrees that there are many good midwives she believes they are medically underqualified to actually deliver a baby (she says that in Australia the moment the baby looks about to be born midwives call for an obstetrician). “Who is the greater trained medical practitioner,” she asks, “someone who has done a course for a while or someone who has done a six-year medical degree?”

Michelle Hemmington co-founded the Campaign for Safer Births following the death of her son Louie in 2011. During the second stage of labour he became distressed and his heart rate deteriorated. She says she knew instinctively that she couldn’t deliver him without intervention (she is only 5ft tall) and asked for a C-section three times. “I kept saying: ‘I can’t get him out. I know I can’t,’ ” she says.

The midwife let her struggle for a further 90 minutes before performing an episiotomy. Louie was born a few minutes later weighing 7lb 7oz and placed on Hemmington’s chest but was he then taken to resuscitation. Thirty-four minutes later Hemmington and her partner were told their son had died. A post mortem revealed it was from brain injury owing to lack of oxygen.

Litigation against the hospital is continuing but a serious incident report identified 19 failings including failure to monitor foetal wellbeing and failure to escalate to a consultant obstetrician when urgent review was required. Hemmington says that talking to other women makes her believe that such incidences are not as rare as is claimed.

“I think [many places] are understaffed and under-resourced and the relationships between midwives and obstetrics is not always good,” she says. When a baby is classed as “stillborn” (as Louie was) there is only an internal investigation and no inquest. The findings, Hemmington says, are not shared with other hospitals but kept internally. “Now midwife-led units are becoming more popular, which makes me worry because births aren’t straightforward and intervention by a doctor may be needed,” she says. “There seems now to be a view that medical intervention is bad. In fact these interventions can save lives.”

One aim of Hemmington’s campaign is to have inquests into certain stillbirths to highlight any areas of substandard care. She believes that in certain cases some hospitals will “push for a baby to be labelled stillborn because a coroner has no jurisdiction [to investigate]”. Indeed, the inquiry report into the Furness General Hospital deaths makes a similar point, noting a “subtle incentive for staff to record a death as a stillbirth where there is some doubt about whether there were signs of independent life” and to “argue to the coroner that holding an inquest would be wrong in law following a stillbirth, as the University Hospitals Morecambe Bay Trust did following one of the 2008 deaths.”

There is a sobering paragraph in the report that reads: “We were distressed to find that not only were intrapartum stillbirths a too regular occurrence at Furness General Hospital, they seem to us to have been treated with far less concern than we expected and as a result opportunities were missed to identify substandard practice.”

Judy Ledger is the founder of Baby Lifeline, a charity that provides multidisciplinary professional training in the maternity sector. She says that tragedies such as those at Furness can “mainly be avoided with proper training” and adds: “The problem is that hospitals have been left to get on with their own training and standards. What we’re trying to do is offer across-the-board training to standardise it”.

A midwife told me that protocols, such as how long you are allowed to push, can differ from trust to trust. Most shocking to her was that blood-test scores for gestational diabetes differ, so that in one area you might be classed as diabetic and therefore high-risk, requiring extra scans and possible early induction, and in another you’re simply not diabetic. “I find that absolutely astonishing and it really needs to change,” she says.

However it is a “myth” that midwives are pressured to promote “natural” childbirth to save money. In fact a hospital gets more money from government for each C-section performed. She believes that most midwives are if anything quicker now to get a doctor to intervene because of litigation fears. Reluctance to send for a doctor might stem from the midwife’s beliefs or from a fear of intruding when things are frantically busy.

“You can get shot down quite quickly if you have a problem that you’re not yet sure is a problem. So you might hang back and see what develops before you go in,” she says. “When you come out of a room and all you can see is doors closed because they’re busy in all of the rooms it can be very difficult to get a second opinion sometimes. You might have to wait until the situation is quite dire before you have their attention.”

Indeed, the Royal College of Midwives renamed its Campaign for Normal Birth (slogan: “Intervention and Caesarean shouldn’t be the first choice — they should be the last”) the Better Births Initiative. Cathy Warwick, the college’s chief executive, says: “It’s absolutely shocking that normal birth is ever pushed beyond the point of safety. I’m extremely concerned that any midwives [in Furness] have been deemed as doing that. We have promoted normal birth for women who are appropriately selected as suitable on the understanding that you continuously monitor whether they remain suitable and have clear policies regarding transfer [of care].”

Warwick says it would be unfair to suggest that any such problems were largely “generational” — ie, older midwives failing to adapt — but that it is important that people in maternity services don’t “get into a rut and think this is the way it’s done here”. There are “pockets around the country where we need to revise education and training to make sure people aren’t getting inward and isolated”, she says.

Heather Paterson and Iain Croft’s son Riley would have been ten on March 25. Croft said at the time that if he could have got in that morgue fridge in place of Riley he would have. He still feels the same today. They will, they say, never be the same again. The Morecambe Bay deaths disturbed them both greatly because they know there are 11 shattered families suffering the same torment as them.

Croft still has panic attacks and flashbacks to that terrible night and says that he becomes anxious around bank holidays because he fears other babies will die because of inadequate maternity cover. He worries that childbirth has become akin to “Russian roulette”.

Paterson believes that although there are many good midwives it is an “antiquated profession” that is out of step with the modern climate. When she became pregnant again with a daughter and another son she understandably did not want midwives involved and on both occasions had consultant-led care and elective caesareans at a different London hospital.

As her newborn daughter began crying the theatre staff were in tears because Paterson said she never got to hear her first baby cry. “The really sad thing,” she says, “is that you have to lose a child to get the care you should have received in first place.”
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