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A consultant obstetrician says midwives and doctors feel demoralised and exhausted amid maternity scandals, staffing shortages and underfunding.
On the condition of anonymity, a consultant obstetrician has shared with Healthcare Today the day-to-day reality of their job, in the wake of Donna Ockenden and Baroness Amos’ unflinching reports into maternity services in the UK.
Working for two decades in obstetrics and gynaecology and many years as a consultant, they look after women with high-risk and complex pregnancies, and those with pre-existing medical conditions. However, they also perform caesarean sections, and work in maternity triage (the obstetric equivalent of A&E) and work with the wider team on the frontline of the labour ward.
The maternity services at their hospital trust are rated good by the Care Quality Commission.
Whether it’s the Ockenden Report, the Kirkup Report, or even going back as far as the Northwick Park Hospital investigation in 2006, the themes are exactly the same: poor escalation, poor governance and teamworking. It’s frustrating because these reports come out, but we don’t appear to be moving forward.
In line with the latest Ockenden Report, we see daily that there are not enough midwives on labour wards and an overreliance on bank and agency staff. We see the training doesn’t go far enough to prepare our newest colleagues for the realities of challenging, busy labour wards. As a result, we frequently see amazing, talented colleagues exhausted, sick or off with burnout or stress.
The frustration builds when the government make grand statements, such as those in the NHS 10 Year Health Plan about investing in maternity and reducing maternal deaths, without any visible impact or evidence of investment on the frontline. All we’ve seen are expectations of services to provide so much more with, at best, the same resources, or in some cases, fewer. It feels like they’re just beating us with the same stick again. For most on the frontline, it’s demoralising knowing we are going to have to meet a new set of recommendations with no additional investment.
If we provided more frontline staff so the acuity is not always at 100% (or more), then the team would have the time to deliver the care expected and the outcomes would naturally get better. If we staffed our labour ward with even one or two midwives a shift, everything else would work much better. When a member of the team phones in sick, it would be more easily absorbed and we would be less reliant on the on-call team members. If there was a “quiet shift” (they almost never happen, and using the ‘Q’ word is forbidden), some of the team could use the time to catch up on their mandatory training, or we could run in situ simulation of emergencies. All of which falls by the wayside when running a rota with no slack. People can engage with the Patient Safety Incident Response Framework and easily attend the after-action reviews and help with projects to stop these adverse incidents from recurring.
At the moment, it feels as if you’re just going from one shift to another, with your feet barely touching the ground.
Decline in continuity of care
I feel privileged as my role gives me relative continuity with the women I provide care for. They will often be seen from early in pregnancy and regularly reviewed in my clinic throughout their pregnancy, so I have the opportunity to build a care provider relationship with them. But continuity is one thing that has deteriorated over time in the antenatal clinics. It’s a real problem because if you see someone different every time, they will have different communication styles and variations in their management recommendations. With changes to plans or advice, the pregnant people ultimately don’t know who to trust and lose faith in the service. Whereas if you build that relationship with someone over a course of six months, then the individuals are much more likely to listen to the pros and cons of their choices. If there is a collaborative approach to care, this will improve outcomes.
It’s not the clinical work that worries me anymore; with years of experience and exposure to many obstetric emergencies, it becomes part of your routine. You know the team will have your back, and we will all work together in the acute emergency. The non-clinical work is the hardest. When I’m next on call, I know that I’ll get to the labour ward, and there will be a queue of people that are waiting to continue their inductions, some of them will have been sat there for a couple of days. You know in your heart we are just not doing these people any service.
Then there will be multiple conversations about how we’re going to get these people across. Mostly met with the reasons why we cannot continue with the inductions because we don’t have any free midwives to provide one-to-one care. Eventually, one or two will come over because they have gone into labour or a midwife has become available. All the time they are waiting, the woman’s frustration, stress and exhaustion are building, which does not put them in a great position for labour. Then something else will happen, such as the neonatal unit will become full, which means that they can’t take any more babies, so then everything has to be rediscussed. This then impacts our elective caesarean section service, which may mean operations are cancelled and squeezed into other lists again, causing disappointment and frustration for the women, leading to often lengthy apologetic conversations that could be avoided if staffing were better.
There is a core group of staff who will do anything for the hospital and will work themselves into the ground until they’re poorly or burnt out, and then they’ll go off sick for a long time. It’s a spiral. The greater the stress, the sicker people get, the more pressure it puts on everybody else.
As Ara Darzi, Baron Darzi of Denham, said in the Darzi Report in 2024, the NHS is full of great people, but they’re all exhausted.
Explosion in governance and reporting
Many hospitals are being asked to make huge savings. As a result, staffing is being kept to a minimum with recruitment freezes and changes to extracontractual work pay. Many staff are saying they’re not going to do any extracontractual or bank work because it’s no longer worth their time. That’s only going to make the staffing problem worse because we rely on people picking up extra shifts to keep the rotas covered. The government says it wants to improve maternity services, but the measures being introduced are making it even harder on the frontline. They say one thing, but it translates into the complete opposite in practice.
We’ve been promised investment, and some of that has happened. Our risk and governance team is bigger than it has ever been, and that has improved how incidents are reviewed. But at the same time, the amount of governance and reporting expected has exploded over the past decade. Plus, there are external investigations and reports to respond to, and a growing number of performance measures to report on.
The problem is that we’ve invested in reviewing incidents, but not in giving people the time to implement the learning. We have endless meetings about these issues, but people don’t have time to do anything to address them.
Families felt they didn’t have a voice
As part of my role, I will regularly see families who have been affected by stillbirths or neonatal losses. As well as those who have experienced obstetric complications or traumatic emergencies. This is a challenging part of the job, but so rewarding when done well, as it allows the woman to make informed choices about if they want to proceed with a further pregnancy and, if they do, go into it with more confidence.
For example, they may have had severe preeclampsia or had a seizure and gone to the intensive care unit. I will talk them through what happened and what we can do in subsequent pregnancies to try and make sure the risk of this happening again is reduced, and how their next baby can arrive safely in the world. Then they will often come back to my clinic in a future pregnancy to ensure continuity of care.
The families in the Ockenden Report weren’t heard, they didn’t feel they had a voice and had to fight for reviews. We can avoid these cases like those by actually being human beings and listening to the people facing us in our clinics.
Martha’s Rule, being implemented on maternity wards, is a positive thing overall if people feel that they’re not being heard by the clinician, which will happen on occasion. They could be a perfectly good clinician, and just be having a bad day. They may have quickly gone to see someone, and then there were six emergencies all of a sudden on the labour ward, so they didn’t have the time to communicate with the patients properly. If I were ever in need of a second opinion as a patient and I felt that I wasn’t being heard, then having Martha’s Rule as a mechanism of being able to get a second opinion is important.
Told to Katie Heslop.
