Story Highlight
– Sophie Dicks experienced a traumatic labor and C-section.
– NHS maternity care found severely lacking, per Amos report.
– High maternal and infant mortality rates in the UK.
– Understaffing leads to poor patient care and outcomes.
– Amy af Ugglas highlights superiority of Nordic midwifery practices.
Full Story
Sophie Dicks faced an unexpected turn of events when she entered labour weeks before a planned caesarean section in November 2023. After having undergone a C-section for her first child, she had hoped for a natural birth this time. However, upon exceeding her due date, her healthcare providers recommended scheduling a C-section for a later date.
Throughout a strenuous three-day labour, Dicks encountered numerous midwives—“too many to count”—though she estimates there were at least ten. Ultimately, she was informed—without undergoing a proper examination—that her labour progression was inadequate because her contractions were not sufficiently frequent. To mitigate the risk of infection, the healthcare team once again suggested a C-section. “But I was made to wait six hours, while still in labour,” Dicks recounted. When she finally entered the operating theatre, complications arose. “They couldn’t get Remi out. I wasn’t told anything, but suddenly an alarm sounded, and ten people rushed in and lifted me upside down, so my legs were in the air. He was born and rushed away, but I was in a mess; I’d lost 3.5 litres of blood.”
Dicks learned later that the medical team was unaware she was in active labour at the time of the procedure. “That blew my mind and sent serious alarm bells ringing,” she stated. Her ordeal echoes troubling patterns uncovered in a recent investigation into maternity services across the United Kingdom, led by Baroness Valerie Amos. This national maternity and neonatal investigation highlighted alarming deficiencies in maternal care, with Amos asserting that frequently, “women were not listened to,” and some were left in critical conditions in hospital settings.
After visits to seven different NHS trusts and discussions with both families and healthcare professionals, Amos expressed concern that despite the urgent need for reform, improvements within maternity care have progressed at a dishearteningly slow pace. “Nothing prepared me for the scale of unacceptable care that women and families have faced and continue to face, alongside the tragic repercussions for their babies and the significant impact on their wellbeing,” she stated. The investigation recorded an astonishing 748 recommendations related to maternity and neonatal care within the past decade, underscoring a systemic failure in providing adequate care.
The experiences detailed by Dicks and others have brought renewed attention to Britain’s troubling maternal and infant mortality statistics, which overshadow many other European nations. A 2022 analysis revealed that the UK’s maternal death rate stood at 9.6 per 100,000 live births, alarmingly high compared to Norway’s 2.7 and Denmark’s 3.4. Additionally, concerning trends in stillbirth and infant mortality rates place the UK behind numerous nations, with its 2021 rate of 4.0 per 1,000 live births ranking 29th out of 38 OECD countries.
The Amos report’s shocking revelations echo failures documented in past reviews, including the Ockenden Review of 2022, which illuminated chronic deficiencies in care leading to numerous maternal and fetal fatalities in Shrewsbury and Telford, calling for immediate actions across all trusts. The Birth Trauma Inquiry Report issued earlier this year similarly urged a complete re-evaluation of care practices, as existing conditions were deemed intolerable.
The question arises: why does the UK lag behind other nations, particularly those in the Nordic region, in terms of maternal and infant healthcare? Anna af Ugglas, the chief executive of the International Confederation of Midwives based in the Netherlands, attributes the significantly lower maternal mortality rates in these countries to the integral role of midwives within the healthcare system. “Midwives are highly respected in Nordic countries—they are seen as essential for gender equality and access to care, regarded as competent and trustworthy professionals,” she explained.
“For decades, there has been a solid tradition of well-trained midwives integrated within the healthcare system, allowing them to operate autonomously with physician consultation as needed,” she elaborated. In these countries, midwives hold a clear and defined role, which facilitates a smoother working relationship with doctors, avoiding ambiguity regarding responsibilities and interventions.
Af Ugglas highlighted that continuity of care is a fundamental factor contributing to positive outcomes, stressing the importance of pregnant women seeing the same midwife throughout their pregnancy and delivery. “The gold standard in Nordic countries aims for continuity of care, ensuring women have consistent support throughout their reproductive journey. The WHO’s recent papers advocate for midwifery models that promote such continuity, given the documented positive outcomes,” she noted.
However, such continuity remains an elusive goal for many midwives in the UK. Rebecca, a midwife from North Yorkshire with over a decade of experience within the NHS, voiced frustrations over chronic understaffing, which prevents her from delivering the care she aspires to provide. “Nobody goes to work intending to give poor care. It’s deeply disheartening to go home feeling like you haven’t been able to do your job properly,” she lamented.
While the place of midwives in maternity care is crucial, several countries beyond the Nordic region demonstrate higher standards in perinatal care. Japan boasts one of the world’s lowest rates of infant and neonatal mortality, attributed to its robust and comprehensive maternity system. Meanwhile, Canada and Australia have also integrated midwifery care effectively into their healthcare frameworks.
Tragically, however, the results of inadequate staffing and subpar patient care can result in devastating consequences. The Amos report cites harrowing accounts of women’s concerns about fetal movements being overlooked, sometimes leading to fatal outcomes. Tom Hender from the West Midlands shared his family’s heartbreaking story, describing how his wife Ewa experienced reduced fetal movements weeks before their first child was stillborn due to a series of missed opportunities for timely intervention and scanning.
Following the delivery of their stillborn child, the Henders have been left grappling with grief and psychological trauma. Hender has become an advocate for systemic change, stressing that failures in the hospital system contributed to their loss. “The system is broken and requires thorough investigation. We needed better support and clearer communication around the risks involved,” he asserted. Their journey underlines urgent calls for reform within NHS maternity services, urging immediate action to prevent further tragedies in the future.
Our Thoughts
The incident involving Sophie Dicks underscores serious deficiencies in maternity care, highlighting several health and safety failures under UK legislation. Key issues include inadequate staffing levels and a lack of continuity in care, leading to miscommunication regarding the status of patients. The absence of proper assessments before surgery violated the Health and Safety at Work Act 1974, which mandates that employers ensure the health and safety of employees and third parties.
The failure to trigger alarms during critical moments of the C-section, thus exposing both mother and child to imminent danger, represents a breach of Care Quality Commission standards that require appropriate response protocols in pressured situations.
To prevent similar incidents, NHS trusts must ensure compliance with the guidelines outlined in the Ockenden Review and improve workforce levels to provide consistent care. Increased training for midwives and staff regarding effective communication and assessment during labour could also mitigate risks. The overarching lesson is the need for a systemic overhaul to prioritize patient safety and properly resource maternity services, aligning with the Care Act 2014 that aims to improve quality of care.
