Midwifery reflections on the Kirkup report

Still working my way through Kirkup’s Morecombe Bay investigation report – it’s a heavy read.

After the RCOG and RCM ‘professional body’ responses, I wanted to hear some midwifery voices on what the report means to us personally, and the care we provide on a day-to-day basis. So I asked some key figures in maternity these questions:

• How do you feel about the report?
• What are your thoughts on: “the ethos of normal or natural birth ‘at any costs’, which resulted in inappropriate and unsafe care” (p.13, 1.4)
• What are the implications for maternity?
• Have you any concerns/ insights?
• What are your suggestions for a way forward?
• Would you like to say anything else?

Here are responses from: (in alphabetical order) Sheena Byrom, Jenny Hall, Mary Newburn, Lesley Page, Rebecca Schiller and Shawn Walker.  Mine is right at the end. There may be more to come, so watch this space.

Sheena Byrom, midwife consultant: “I feel great sadness and disappointment reading the report. Sadness for the devastating suffering of families affected by loss and trauma, and for the staff who were caught up in a broken system. Disappointment that organizational processes and pressures were undoubtedly the greatest influence over human action.

Protecting normal birth is a midwife’s core function, and many work hard to support and promote such an ethos where they work, often in difficult circumstances. Problems arise when there is a lack of mutual respect between professional teams, and a ‘them and us’ culture between groups of midwives. But I have honestly never met a midwife who compromised safety in the pursuit of ‘normal birth’ – in fact, on the contrary. In the main midwives err on the side of caution, and through fear will sometimes practice defensively and involve medical teams for reassurance.

A maternity services review is being planned, and is welcomed. This gives us the opportunity to articulate the need for improved leadership, midwifery representation on boards, greater focus on the need for improved attitudes, mutually respectful relationships and the importance of collaboration. We need to ensure there is a commitment to reduce the fear that initiates most of the actions taken in maternity services.

The report highlights organizational malfunctions in one Trust at every level, and includes faults of each professional body, yet the focus of attention in the report and in the media is mainly on midwives, which I feel is worryingly unjustified. Learning from mistakes is crucial, but must take place in a no-blame environment.

Improving safety means more than increasing risk management strategies. The quality of relationships directly affects maternity care and outcomes. Midwives and doctors need to be listened to, nurtured, developed and encouraged to maximize their potential to provide sensitive, compassionate maternity care.”

Jenny Hall, senior midwifery lecturer, Bournemouth University: “I’m shocked, saddened for the families involved.  So sad that this was going on in maternity service for so long without it being recognised or dealt with and was indicative of the way the NHS has been managed over the past 20-30 years. Cost cutting at all levels and burying heads in the sand- culture of power and people being squashed if they speak out.

I have not experienced the ethos of normal or natural birth ‘at any costs’ anywhere else. Usually it has been the opposite – a culture of medicalization or a culture of midwives and doctors working together for the wellbeing of women and their babies. This ‘ethos at all costs’ is highly unusual and against the Midwives Rules of practice. This was not just about the midwives but also doctors that were ineffectual.

We have already had some repercussions in the first change in Supervision since the 1902 act. The implications should be that we should examine ourselves and ensure this does not happen again but also to ensure we work closer with the medical profession.  The implications are around education and ensuring midwives and doctors remember accountability and that we become more transparent in our practice

As a high profile situation I am concerned that the midwives are the only ones vilified in this when it was clearly a wider situation of management as well. I am concerned that the midwifery profession as a whole will be kicked by this when it is evident that this is a small group in a poisonous culture. But the impact of this on families has been so devastating that questions have to be asked. We must learn lessons but also keep hold of the evidence of how GOOD midwifery care works.

Moving forward will require dialogue at all levels, no burying anything, facing up to the issues and ensure we make changes in cultures that are controlled by anyone is power-hungry,  ensure there is no conflict in any roles, women babies and families must come first and services must match this.”

Mary Newburn, maternity activist and parent advocate: “It’s tragic that there were 20 major failures of care at the Furness General during 2004-2013. These led to one maternal death and 11 deaths of babies that the Kirkup enquiry felt would have been prevented with different clinical care. It took too long for parents’ voices to be heard. What can be learnt? The investigators’ list of problems include ‘poor clinical competence, insufficient recognition of risk, and failures of team-working’. Does ‘inappropriate pursuit of normal childbirth’ rightly have a place there, too?

In my experience, leading advocates of normal childbirth are very clear about the need for clinical competence, good communication, understanding and mutual respect in the multi-disciplinary team and continuous assessment of risk. These are the secrets of success. The Furness General is geographically isolated with relatively few births. These kinds of services can struggle to attract and retain excellent clinical leaders and keep up with developing best practice.

I feel it is vital that those in positions of power do not to pillory ‘normal birth’ following Kirkup. Despite reforms, many women still feel that their pregnancy and birth are not their own when making babies, and their mind and memories seem to matter little. Good services are built on team work, with competent, up to date, questioning and responsive midwives and doctors who respect women and each other. Add in engagement with parents, as individuals receiving care and as advocates for shaping services, and services really flourish.

So, with some trepidation I welcome Kirkup’s call for a review of maternity care in isolated, rural areas. And give a resounding ‘Yes!’ to the call for a robust MSLC (maternity services liaison committee) for the Furness General, and all other units. Please note CCGs. The ball is in your court!”

Lesley Page, president of Royal College of Midwives: “I feel so sad about the grief of the families who suffered, grief compounded by the fact that nobody listened and failure of response and justice. Determined to learn from it.

The press has picked up on the report’s emphasis on “the ethos of normal or natural birth ‘at all costs’ at the unit which resulted in inappropriate and unsafe care” (Kirkup, 2015, p. 13, 1.4.) I searched carefully to find out what was the basis of this emphasis but couldn’t find much. I would have liked to have understood the clinical situations better. We need to support normal birth to improve health so such an ethos would not make sense.

We need systems of care and resources that help us give of our best. Morecambe Bay was an example of how to detract from humane, effective safe care. It will be important to ensure that we have strong midwifery leaders, working with others, supported to truly lead, in healthy cultures of care. In any unhealthy culture leaders may not stand a chance.

I’m concerned that response might be to increase, or allow an increase in the intervention rate and unnecessary interventions and to detract from the work of developing midwife led care and choice of place of birth for women. Avoiding unnecessary intervention is crucial to increasing safety. This needs skilled midwives and doctors, relationships within systems and pathways without rocks cliffs and boulders in them. It needs women to be involved in decisions about their care and user and public involvement in monitoring and developing services.

We must learn from the report. The maternity services review to be conducted by NHS England will be important. We need to recognise the evidence on what improves safety of birth and act on it. It will be important to use quality and safety improvement methodology in the health services.

Staff and all those who were part of what happened in Morecambe Bay carry a huge burden, this includes people at every level, government, providers, commissioners and regulators. Many will have been doing or trying to do their best. I hope any incoming government will take notice of the sheer disorganisation that comes from mismanaged reorganisation. Systems have people in them, those people are human, sometimes super human efforts are required to manage well amongst turmoil, there are few super humans. There was lack of leadership but I think the situation would have made it very difficult for leadership to flourish or be effective.”

Rebecca Schiller, co-chair Birthrights, doula: “The Kirkup report raises a series of valid questions and serious concerns about maternity care in England – many of which are applicable far beyond our national borders. It is now vital that we move forwards to answers and I hope that a national maternity review will be a step towards that.

However, in the wake of terrible tragedy, it is all-too-easy to be reactive rather than reflective. There is a risk of looking only to solutions to surface-level problems. It is crucial that this review does not only seek to fix the problems at the end of the chain of linked failings without looking back at the systems, structures, cultural values and resource-issues that cause clinicians to fail spectacularly in their duty of care. Genuine bad practice will sadly always exist. Systems need to be able to identify this and deal with it swiftly taking women’s feedback and complaints seriously and refraining from defensive and obstructive behaviours.

But bad practice is not the demon here. The overwhelming majority of clinicians want to practice safely, compassionately and professionally. They want to deliver care that matches women’s needs and expectations and there is an evidence base to draw on to show how this can be done. A thorough review of maternity services should identify where and why they don’t support health care professionals to offer this kind of care. Women have for too long been pushed through a system that doesn’t recognise their individual needs. This is unsafe and unsustainable. I hope that the tragedies at Morecambe Bay are a prompt for a genuine change in the models and culture of maternity care.”

Birthrights’ response is insightful on the Morecambe Bay midwives’ exclusion of obstetricians from the unit as ‘unlikely to have been principled adherence to evidence-based care’ and notes that ‘it is a sad consequence that the pursuit of well-evidenced maternity care has been conflated with their impropriety.’

Shawn Walker, midwifery lecturer, City University London. Breech Birth Network. “Like many midwives, I welcome the Kirkup report, though it was hard reading at times.

Very few women and midwives wish to pursue an ethos of normal birth at all costs. But a healthy desire for normality can become sick and twisted within a dysfunctional system, like a family plagued by unhealthy obsessions and addictions, in which everyone feels lonely, together. Sometimes one or a few individuals are able to make these dysfunctions work in their favour for a while, but inevitably cracks emerge. When one individual acquires an unchallenged amount of power by assuming multiple roles in the risk management process, the collaborative system of checks and balances characterising healthy organisations becomes unbalanced.

Used wisely, risk management and midwifery supervision are powerful tools, which enable organisations and individuals to change, improve, and grow. They can and should help health professionals to become aware of their errors, strengths, and developmental needs. These processes should be rigorous, transparent and welcomed. Insight should never be feared and avoided. The Kirkup report points the way to how health services can find health. It is not about natural birth or medical supremacy. Safety requires respectful, collaborative communication amongst all professions. Safety requires working environments where people are able to say, “I’m concerned,” without being overridden or overriding someone else’s concern. Only by being rigorous, compassionate and honest with each other can health professionals hope to provide care, which is all these things for the people who trust them with their lives.”

Olivia Armshaw, student midwife: “Treading carefully, respectful of the grief of those involved in the tragedies which distressingly resulted from substandard care… As a soon-to-be qualified midwife working in a busy NHS trust, alongside many highly competent, compassionate, careful, sensitive and emotionally intelligent midwives, I don’t recognise the picture reported at Morecombe Bay, thankfully the stories seem a world away from the care being given around me, and the feedback from women.

It doesn’t ring true that normal birth is pursued at all costs. Yes, we look for opportunities to bring normality and ‘low risk style’ care to those with complex needs, to humanise where possible. Yes, we offer homebirth to women who want it and for whom it’s safe. Yes, we have midwife-led birth units. But there is a collaborative approach to care with obstetricians, with weekly interprofessional meetings on delivery suite to review cases and discuss how care could be improved. We are not reckless or gung ho and never is there a cavalier attitude to normal birth. If anything, I think we could do more to maximise physiology and intervene less.

I witnessed how the Francis report demoralised midwives and some felt it became another stick to beat us with. I really hope the Kirkup report doesn’t have the same function, used by those how want to sling mud (or worse), and undermine the whole midwifery model of care. I hope we can extrapolate the learnings and work, mindfully and collaboratively so failings are not repeated. First we need to identify the lessons in a very specific, not a generic way that says ‘normal birth is bad’, ‘midwives are all reckless and unprofessional’, which are wrong and dangerous conclusions to jump to, with a whiff of an age-old witch hunt.”

I feel the Lancet midwifery series lights a way forward, supporting a shift from fragmented maternal and newborn care provision that is focussed on identification and treatment of pathology to a whole-system approach that provides skilled care for all. (Lancet, Volume 384, No. 9948, September 2014 )