Supporting Safe Maternity Care
In this piece, RCOG President Dr Alison Wright comments that every maternity service should be designed around the changing needs of women and babies, with continuously reassessed risk, one multidisciplinary team, and a culture where escalation is welcomed.
Continuing evidence of avoidable harm in maternity services should concern everyone involved in the care of women and babies.
Our new Secretary of State has announced that maternity and neonatal care is her priority, giving us a unique opportunity for positive change.
Over recent years, investigations into maternity services have repeatedly identified familiar problems: workforce pressures, poor multidisciplinary working, failures to listen to women and families, delayed escalation, defensive cultures and a failure to learn from previous incidents and inquiries.
All of these issues require action. But we must also be prepared to ask a deeper question: are maternity services themselves consistently designed around safe care?
For many years, maternity policy and practice have sought to reduce unnecessary medical intervention. These are important aims. Intervention without clinical benefit can itself cause harm, and women should be supported to make informed choices about their care.
But the desire to avoid unnecessary intervention must never become a reluctance to intervene when circumstances change. The overriding shared purpose of maternity care is simple: to provide safe, personalised, and compassionate care that achieves the best possible outcome for every woman and every baby.
Moving beyond fixed ideas of risk:
An area that deserves particular attention, and has been highlighted in reviews by Donna Ockendon and Baroness Amos is the way we consider risk.
Historically, maternity pathways have divided women into artificially simple, binary categories of ‘low risk’ and ‘high risk’. These classifications can be useful in planning care, but pregnancy and childbirth are dynamic processes and the risk does not remain static.
A woman whose pregnancy has been entirely uncomplicated can develop serious complications. Labour can change rapidly. A baby who has previously shown no signs of concern can deteriorate within a short period of time.
Our maternity system therefore needs to be built around continuous awareness and reassessment of risk, rather than an assumption that an initial designation of ‘low risk’ will remain appropriate.
This also requires a culture in which escalation is viewed positively. Calling for another opinion, involving obstetric, anaesthetic or neonatal colleagues, is good maternity care.
We must be willing to examine culture:
We also need to be prepared ourselves to ‘hold up the mirror’, and examine the professional cultures and philosophies that have shaped our maternity services.
The findings of maternity investigations should make us all reflect carefully on our ways of working. Repeatedly, we have seen examples of warning signs being missed or minimised, women and families not being listened to, reassurance continuing for too long and opportunities for earlier escalation being lost.
We should be willing to ask whether aspects of professional education, language, leadership and service design have unintentionally contributed to these patterns.
This is an argument for intellectual and professional humility: a willingness across all maternity professions to examine the assumptions that influence our practice and change them when the evidence tells us we should.
One maternity team:
There is another important shift we need to make. Safe maternity care cannot be built around professional silos. Obstetricians, midwives, anaesthetists, neonatologists, maternity support workers and other professionals are not separate services working alongside one another. They are members of one maternity team caring for the same women and babies.
The safest services are those where professional boundaries do not obstruct communication; where concerns can be raised regardless of hierarchy; where escalation is welcomed; and where responsibility for safety is genuinely shared.
Women and families must also be central members of that team. When a woman says that something does not feel right, that information matters. Listening is not simply an issue of compassion or experience; it is a fundamental component of safe care.
Designing maternity services around safety:
We therefore need to reconsider what our maternity system is optimised to achieve.
A safety-optimised system would not promote a particular mode or experience of birth as the measure of success. The right birth is the birth that is right for that individual woman and baby, based on the clinical circumstances as they evolve and her informed decisions.
It would replace static concepts of risk with dynamic assessment throughout pregnancy, labour and the postnatal period. This would regard escalation not as a deviation from the intended pathway, but as evidence that the system is responding appropriately to changing circumstances.
It would replace professional silos with genuine multidisciplinary teamwork and shared accountability.
And it would combine compassionate reassurance with vigilance, curiosity and a willingness to act when something ‘does not seem right’.
A shared responsibility:
The debate about maternity safety has previously been polarised. Safety versus choice is a false dichotomy. Women should not have to choose between a positive birth experience and safe care. We should facilitate both.
Nor should this conversation be about blaming one profession. Obstetricians and midwives must be prepared to examine their own practice and culture, just as critically as we ask others to examine theirs.
Every profession involved in maternity care has a responsibility to learn and improve.
The recurring tragedies exposed by maternity investigations tell us that incremental change is not enough.
We need to ask fundamental questions about how services are designed, how professionals are educated, how risk is understood, how teams work together and what behaviours our systems encourage.
Our starting point should be straightforward: every maternity service should be designed around the changing needs of the woman and baby in front of us.
Supporting physiological birth when it is safe and desired is part of that. Acting quickly and decisively when circumstances change is equally part of that.
If we can build a maternity culture that holds those principles together, we will be taking an important step towards the safer maternity system that women, babies, families and the professionals caring for them need and deserve.
- RCOG Maternity Safety programme, available here.
- Find out more about RCOG membership advice and support service information here.
- RCOG Supporting our doctors
- For media enquiries, contact the RCOG press office: pressoffice@rcog.org.uk or +44 (0)7986 183167