‘Nothing prepared me,’ said Baroness Amos as she released her ‘reflections and initial impressions’ about England’s maternity and neonatal services, ‘for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing.’
Amos’s words today paint a bleak picture of English maternity services, staffed by people who often don’t care, don’t listen, and deliver worse outcomes for the working class and people who aren’t white. It’s a picture that many parents – including myself – recognise. But is it right to suggest that black mums are being discriminated by the NHS?
When my wife went into labour, the obstetric registrar, faced with the labour failing to progress, did as little as possible. They dishonestly stretched out inaction until the end of their shift, when a new registrar, taking one look, rescued us – barely, and at significant cost to mother and baby – with emergency action.
Babies and women should not die because of poor care
That registrar happened to be black and we happened to be white, and the events had nothing to do with either fact. I have worked in the NHS for thirty years; I can make a reliable guess at a doctor’s quality and work ethic after a thirty-second chat in a corridor, and I can’t do it by noting the colour of their skin. But had we been black and that registrar white, I can see how we might have suspected racism; how, with the best will in the world, we’d have wondered if we’d been brushed off for how we looked.
The NHS, a profoundly diverse employer, seems an unlikely candidate for a deeply racist organisation, and there are those primed to see prejudice everywhere. But even the most charitable of minority or deprived patients will reasonably wonder whether prejudice is to blame when they’re treated badly and come to harm. Some will be right and some won’t; properly understanding what’s gone wrong is vital either way.
How do maternity outcomes in Britain compare with other developed countries? The answer is that we’re not terrible, but we’re very far from the best – a bit below average might be a fair summary. Comparison is messy because different countries (and different agencies within countries) count them in different ways. Many European countries record fewer maternal deaths – often about half the number – but for neonatal ones we’re about average.
Not being white makes death more likely. But being poor makes death more likely also, and it’s misleading to cite data on ethnic risk without adjusting for underlying deprivation. Health outcomes are worse for the poor across countries and across time; the NHS should be trying to help, but shouldn’t be blaming itself for failing to solve inequalities that can’t be cured by medicine. Having a baby isn’t an isolated technical issue, with outcomes determined by the quality of healthcare. Failing to give deprivation-adjusted figures is misleading, and all the more so because while ethnic disparities are narrowed by adjustment, they still remain. The problem is real and merits serious attention – which means clarity, not distortion.
Some people will always be unsatisfied, even when everything goes well. The most resilient of us struggle when events go badly, and they don’t get much worse than losing a baby or seeing them suffer and be harmed. We are right to care deeply about the quality of NHS maternity services.
We also care because we worry that the NHS overall is a failing service delivering bad care. Perhaps this is why Baroness Amos’s preliminary comments have received such attention. My experience is that we’re right to worry. Opinions differ as to what form change should take, but many of my most left-wing colleagues now openly say, much to my astonishment, that the NHS is failing and needs profound change. Baroness Amos noted there have been a ‘staggering’ 748 recommendations about maternity and neonatal care recently:
This naturally raises an important question: with so many thorough and far-reaching reviews already completed, why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country?
Baroness Amos is hopeful her own review – due next year – ‘will lead to systemic reform … as well as propelling systemic change’. Perhaps it will amount to hand-wringing and grudges, with statistical innumeracy painting a misleading picture and several hundred new recommendations that make nothing better and some things worse. If 748 recommendations haven’t made things better, another couple of hundred may not be the answer.
The need for improvement is urgent and real. Mistakes, failures, and poor communication will haunt even our best efforts, but babies and women should not die because of poor care. Whether another review will save them is far less clear.
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