The decision by the Royal College of Midwives to withdraw its decade-long campaign for “normal birth” has come much too late for my own son, Joshua, who sadly died nine days after being born, but is a welcome step. The approach for too long influenced a style of care in maternity wards that put lives at risk.
These were the words spoken by Cumbria coroner Ian Smith, as he began summing up the inquest into the death of Joshua, on 6 June 2011: “With advances in medical science and techniques, childbirth has become safer and safer, to the point where we now expect children to be delivered safely. Now, I will have to say in truth, the process is a highly dangerous event, and you could make a glib remark that the most dangerous day of anybody’s life is their first day of life.”
Joshua had died two and a half years earlier because of poor care in the 24 hours after his birth at Furness general hospital in Cumbria. Signs that he was suffering from a serious infection that should have resulted in speedy medical referral were not acted on by the midwives looking after him. Instead, Joshua’s first contact with a doctor came some 24 hours later when his mother found him collapsed in his cot and called for help. By this time, however, it was too late.
Despite being transferred to two different neonatal intensive care units and putting up a fight to be proud of, Joshua died eight days later. His left lung was more damaged from the infection than the consultants looking after him had realised. He died from profuse internal bleeding.
Before his death Joshua received world-class care at the Freeman hospital in Newcastle where staff perform miraculous work to save the lives of babies every day. In those final days Joshua was kept alive by a heart and lung machine and attached to a multitude of tubes, wires and medical devices, and with constant one-to-one care.
Joshua’s brief time in this world was as medicalised as any experience of maternity care could be, yet his dire predicament could have been avoided with the simplest and cheapest of medical interventions. Five minutes of a doctor’s time and a single dose of antibiotics at the right moment would have saved his life.
Following Joshua’s death the trust told us that the circumstances of what happened were unique, but in the years since a fuller picture of the truth has slowly emerged. In March 2015 an independent report by Dr Bill Kirkup found that 11 babies and one mother had died due to linked failures in care at the same maternity unit.
The report found that relationships between midwives and doctors on the unit became “dysfunctional” and described how care became strongly influenced by a small number of individuals whose overzealous pursuit of the natural childbirth approach “led at times to inappropriate and unsafe practice”. The report quotes one witness saying there were “a couple of senior people who believed that in all sincerity they were processing the agenda as dictated at the time … to uphold normality”.
It isn’t hard to see why the national agenda was perceived this way. For more than a decade the RCM has run a “campaign for normal birth”. Its published guidance includes tips for midwives such as “wait and see”, “trust your intuition”, and “justify intervention”; advice clearly aimed at influencing the behaviour and decisions taken by midwives at critical moments during childbirth.
The objective of delivering maternity care in a way that minimises the chances of unnecessary interventions is laudable and right, but to seek to achieve this through a top-down, national campaign aimed at influencing the frontline actions of only one discipline critical to providing safe maternity care is a flawed approach.
The consequences have been catastrophic. In the years since Joshua’s death, I have heard from dozens of families who have lost babies or whose babies have suffered serious harm due to themes I recognise from losing Joshua. I regularly hear from mothers who say they felt pressured towards achieving a “normal” delivery without their concerns and wishes being listened to.
In June the Royal College of Obstetricians and Gynaecologists published the findings and recommendations of its Each Baby Counts project. This work looked at the 1,136 cases where term babies had died or suffered brain damage in 2015. In 25% of the cases the quality of the local investigation was too poor to make a judgment, but of the rest the vast majority (76%) were judged to have been avoidable. The life-changing impact on families, staff and communities of these events cannot be overstated.
The report’s recommendations are telling. Instead of “wait and see”, the emphasis is on training and maintaining situational awareness. Rather than “trusting intuition”, the report recommends all staff “should be empowered to seek out advice from a colleague not involved in the situation who can give an unbiased perspective”.
When coroner Ian Smith made his comments back in 2011, he was right; the most dangerous day of our lives is the day we are born. The good news is that we know how to make maternity services safer. Evidence from the very best units, for example Southmead in Bristol, is that safe maternity care is best achieved when midwives and doctors work as one team, not operating in silos with one group perceiving the other as a threat. We now have the opportunity to build collaborative approaches to improving maternity services, involving all members of the multiprofessional team essential to providing safe care.
Not only can we reduce the stigma for women who don’t achieve a “normal” delivery, we can now also work to reduce the chances of preventable deaths like Joshua’s through ensuring that ideology is never again positioned above outcomes.
• James Titcombe OBE is a patient safety campaigner and father of Joshua Titcombe, who died nine days after being born at Furness general hospital in 2008. Previously he worked with the Care Quality Commission as national adviser on safety, and now works with Datix as a patient safety specialist
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