Maternity Services - Motion to Take Note

– in the House of Lords at 11:51 am on 25 January 2024.

Alert me about debates like this

Baroness Taylor of Bolton:

Moved by Baroness Taylor of Bolton

That this House takes note of the delivery of maternity services in England.

Photo of Baroness Taylor of Bolton Baroness Taylor of Bolton Labour

My Lords, I am pleased to have this debate today. I thank those who have put their names down to speak. It is really interesting to see the level of expertise on this subject here, which proves the value of this House in contributing to wider debates.

One of the reasons that I wanted to discuss this issue was the pressure on maternity services that I have been hearing about in my local area. In Kirklees, we have no NHS birthing facilities whatever; it is one of the largest metropolitan areas in the country. The unit at Huddersfield Royal Infirmary was suspended more than 12 months ago and the Brontë Birth Centre in my former constituency of Dewsbury, whose opening I remember with a fanfare as something to be celebrated, has been closed since August 2022. The basic reasons for these closures have been the crisis in staffing and the level of staffing shortages. The local trust is trying to reopen the Brontë centre, working with a neighbourhood trust, but the problems of staffing are having a real input and will be a deciding factor.

No one can doubt the critical importance of maternity services. Those of us who have given birth will recall many details, good and less good, of that experience. The experience of maternity care can affect the future of both mother and baby. A difficult birth experience can affect bonding and early relationships—a point emphasised to us by the Royal College of Psychiatrists. Everybody who is involved in maternity services will know the significant responsibility that they have. Thankfully, most pregnancies end in the birth of a healthy baby, although that in itself does not mean that the mother’s experience has been optimal. On the other hand, some expectant mothers have their own views of what their experience should be; sometimes, those views are not realistic and can create extra pressure on midwives and others. Locally, I know that the trust has reported more high-risk women wanting births in settings designed for low-risk women, creating extra pressure and highlighting the complex problems that many midwives have to face.

I want to start with the recent important reports on the overall state of our maternity services. The report from the Care Quality Commission is absolutely critical here but I believe we have all received many briefings from mothers of babies, the Maternity & Midwifery Forum, the Nuffield Trust, Mumsnet, SANDS, the Royal College of Obstetricians and Gynaecologists and, of course, the Royal College of Midwives. They have all consistently reported a very alarming situation.

The Care Quality Commission tells us that maternity services were under pressure prior to Covid and that that has worsened. Covid did not help but we cannot continue to use it as an excuse for all the failings in all our services across the board. The pressures on maternity services have been building for more than a decade. The commission also tells us that almost half of all the maternity services inspected in 2023 were rated as either in need of improvement or inadequate—an increase on last year, with things moving in the wrong direction.

Many factors have been highlighted by the CQC. Staffing shortages—especially retention issues, which I will come back to in a minute—are top of the list but it has also reported systematic racism, leadership issues, and workplace and environment issues. All of these are significant and each needs attention but we should not lose sight of the overall situation and the fact that nearly half of these units are causing concern. In those circumstances, we need to stop and think about what needs doing—and doing urgently. I know that there has been considerable ministerial churn and that current occupants may try to distance themselves from previous decisions. Although new Ministers must say that there should be greater emphasis on women’s health, et cetera, the same party has been in government for 13 years and decisions taken during those 13 years have made the situation worse. I think that Ministers in that Government are culpable.

To my mind, the most significant problem is clearly the shortfall in staffing, in particular the imbalance in the workforce because of retention problems. The fact is that many senior midwives, gynaecologists and obstetricians are leaving their professions. There are concerns about the number of students going into midwifery and their experience but the problems of retention make the situation critical.

Earlier this month, the BBC reported on midwives being concerned that staff shortages were causing safety issues. One midwife reported that she kept patients safe only by the skin of her teeth; another said that she had quit because she could not face the possibility of the consequences of poor care. I know of one experienced midwife who left her chosen profession after being in sole charge of six women in labour and being afraid for her own mental health because of all the pressures that that responsibility brought.

The Royal College of Midwives says that staffing is the most important issue. We hear that some trusts have one in five jobs unfilled. In Kirklees, the figure is 18%, but it is not a matter of just getting more students into midwifery. Retention is a serious problem and burnout is a real issue. If we cannot retain experienced midwives, we cannot give student midwives the support and the mentoring that they need during placements.

There have been some suggestions that existing midwives feel threatened by some of the training changes that were introduced a few years ago, and there is always a question about the balance between theory and practice. Certainly, the profile of students in midwifery and nursing generally has changed. I know from my time as chair of the University of Bradford, which has a fantastic department in this respect—maybe the Minister would like to visit—that the profile of students coming into nursing has changed significantly, especially when bursaries were cut by this Government. The intake of mature students declined sharply and immediately, and it has not fully recovered. It has been pointed out to me that having mature students among the student group helps everyone to develop and understand what all the pressures can be. Of course, many students are feeling the cost of living crisis and want to work to survive financially, which is obviously not easy if you are on a midwifery course. I worry about the figures for those dropping out of their courses in the early years.

One factor that particularly worries me is that I am told that there is less continuity of supervision of students on the ward during placement. Each student used to have one named mentor, but I am told that this is no longer the case and that students therefore report that they no longer feel part of a team or that they belong, and that this was also affecting the drop-out rate. Overall, this is a worrying picture. Unless the Government address the retention issue, we will not make the substantial improvements that we need.

I must also talk about maternal mortality. The latest report shows that it has risen to its highest rate in 20 years. A key finding is that the maternal death rate for black women is three times higher than that for white women; for women from Asian ethnic backgrounds, it is two times higher; unsurprisingly, women living in the most deprived areas have a maternal mortality rate twice as high as that for the least deprived. This is not a revelation; other reports have talked about it for a long time. There is no excuse for a lack of action here. I note that the Select Committee in the Commons pointed out that, at the time it was writing its report, the Maternity Disparities Taskforce had not met for nine months. That cannot be acceptable and shows a worrying level of complacency.

I have outlined a very depressing situation, and urgent action is needed. Midwives and others deserve credit and recognition for the work that they do—my noble friend Lady Thornton will tell us about the remarkable achievements in her area of dealing with the consequences of female genital mutilation, and I know from a colleague in the other House, Jess Phillips, that midwives are often critical in helping women escape from abuse—but, overall, we have a crisis. For such a significant service as maternity, in 2024 this is unacceptable. It is up to the Government to provide a proper lead to solve this. I emphasise again that the No.1 priority must be the retention of experienced nurses and midwives. We need a raft of measures to reduce the pressure on midwives and allow them to feel that they can do the job that they are trained to do and want to do to the level that they want to achieve. If the retention issue is not tackled urgently, there will be no space to deal with all the other issues such as updating training. This is all against a general backdrop of serious health inequalities which exist in this country anyway.

We are now in 2024. It is just wrong that maternity services are causing such concern. Every woman deserves the best while pregnant and during childbirth, and every midwife deserves the right conditions in which to work. The Minister said at Question Time earlier that he believed in evidence and common sense. I urge him to attach that common sense to the some of these problems that we are facing this year.

Photo of Baroness Cumberlege Baroness Cumberlege Conservative 12:05, 25 January 2024

My Lords, it gives me great pleasure to follow the noble Baroness, Lady Taylor of Bolton, and thank her for a very interesting and incisive speech. I see that congratulations are being offered to her right now and she deserves them.

One thing that struck me as the noble Baroness was speaking was how important it is that we concentrate on relationships. We must consider all the relationships involved—the parents, the rest of the family and grandparents perhaps—but the most important is the relationship of the staff with the women and their babies. We know that there is huge pressure on midwives at the moment—the noble Baroness raised that issue.

This is a very important debate, and I am extremely pleased that the noble Baroness has taken to the opportunity to raise it. She and many other Members of the House of Lords feel strongly about maternity services and the beginning of new life. The way in which women and their babies are looked after is critical to the well-being of this country. It is a very interesting debate to have raised and I thank her warmly for it.

Maternal mortality rates are at their highest for 20 years. That is quite shocking and really must be addressed. I hope that through this debate we will raise the issues that are important.

I want to say something about when I chaired the National Maternity Review. I was asked to do it by the chief executive of NHS England, who was then Sir Simon Stevens—now the noble Lord, Lord Stevens—and I was given the task of completing the review in nine months, which seemed a very appropriate time. We published our report in 2016 and called it Better Births. It set out five years in which to plan and work towards improving maternity services in England. I was fortunate to have a wonderful, expert group of people on the review team, which was hugely helpful. The important thing we did was to go out and listen to the women of England, their partners and their families, and to the staff who provided maternity services. We listened and we learned from them, not just women who were already mothers but women hoping to become mums in the near future. We heard uplifting, inspiring stories of good maternity care and good outcomes, but we also heard some truly sad stories where care had not been good or outcomes had been devastatingly bad.

What we heard guided us, and the five-year plan we set out was based on what women told us they particularly wanted. At the core were two things that we believed would raise the quality of care and improve safety, leading to better births. The first was that women wanted, and felt they needed, the same midwife, or small team of midwives, throughout the maternity journey. They wanted a relationship based on trust and mutual respect. They wanted a midwife, or midwives, who knew them, understood them, and respected their birth plans and the choices they were making. We call that continuity of carer.

The noble Baroness, Lady Taylor, has raised this afternoon the issue of continuity. We know that continuity leads to safer care and better outcomes for the mum and the baby. Yes, continuity may be challenging in the face of workforce pressures, but we need to be much clearer that continuity is the model of care that we want to see. I think that that is what the noble Baroness was stressing, and I support that.

Secondly, women and their partners want to feel and know that their continuity of care is shared, around them and by them. We call that “personalised care”. It is centred on the woman and her baby, based around their needs and decisions, and where they have genuine choice—informed choice, but with unbiased information. Too often care is done to women and babies, rather than chosen and shaped with and by them. I know that, when staff are under huge pressure, taking the time to understand a woman’s choices and build care around her may be really very difficult, but that is what we should strive for, for all women.

Continuity and personalised care were at the heart of the five-year strategy. They stand at the heart of turning the phrase “better births” into reality. Today’s reality falls short on both continuity and personalised care. Our country is still one of the safest in which to give birth—I want to stress that—and we have met some of those wonderful staff who run our maternity services. But the evidence tells us that we are not achieving the progress that we could and should.

The most recent MBRRACE report on maternal mortality tells us that 293 women died in pregnancy or within 42 days of the end of pregnancy in the three years between 2020 and 2022. That is a significant increase over the previous years, and it excludes Covid-related deaths.

The CQC Maternity Survey 2022 tells us that 10% of maternity services are inadequate and that 39% require improvement. I was delighted that the noble Baroness, Lady Taylor, mentioned the work of the CQC, which is so important, but the figure of 10% of maternity services that are inadequate and 39% that require improvement accounts for nearly half of all services. The CQC says that safety and leadership are particular areas of concern, and they need to be addressed. We are all sadly familiar with the series of local failings in maternity care and the inquiries that have followed. I am thinking of Morecambe Bay, Shrewsbury and Telford, East Kent and Nottingham; those are just examples. Parents who have been involved in those inquiries are now calling for a full national inquiry, and I think they are right.

My Better Births report was published in 2016 and had a five-year plan, but those years have now passed. I believe that we need a fresh strategic national inquiry and a new coherent and practical plan for the whole maternity system. We need to tackle the issues of poor quality and poor outcomes. We need to listen to women and their families, and the staff who are there to care for them, and we need to be guided by what the evidence tells us will lead to better births, to make them safer and as a good an experience as is possible.

Finally, I would like to repeat something from the letter I wrote to the women of England at the start of the Better Births report in 2016:

“The birth of a child should be a wonderful, life-changing time for a mother and her whole family. It is a time of new beginnings, of fresh hopes and new dreams, of change and opportunity. It is a time when the experiences we have can shape our lives and those of our babies and families forever. These moments are so precious, and so important. It is the privilege of the NHS and healthcare professionals to care for women, babies and their families at these formative times”.

I hope those words might play a part in setting the tone and direction for what I believe is now needed: a fresh plan for maternity care.

Photo of Baroness Warwick of Undercliffe Baroness Warwick of Undercliffe Labour 12:17, 25 January 2024

My Lords, I thank my noble friend Lady Taylor, for introducing this timely debate. It is an honour to follow the noble Baroness, Lady Cumberlege, with her long and distinguished engagement with many health issues.

I want to highlight some numbers. The Royal College of Midwives estimates that there is a current shortage of midwives across England equivalent to 2,500 full-time staff. While the NHS workforce in England rose by 14.1% between December 2019 and March 2023—that is almost 160,000 full-time equivalent members of staff—the number of midwives over that same period rose by 1.1%, or just 247 additional midwives. The impact of this shortfall, to quote the RCM, is “stark and sobering”.

Staff shortages mean women and their babies are not receiving the high-quality care midwives want to deliver. But it is not just that staffing levels simply have not kept pace with demand. At the same time, a rise in more complex pregnancies—whether due to increasing maternal age, increasing obesity in pregnancy or pre-existing medical conditions, all of which may place women at high risk of complications—has resulted in pregnant women often requiring more care and more time with midwives so that these issues can be picked up.

The last few years have also seen a significant year-on-year drop in students studying nursing, with an inevitable impact on the numbers who go on to midwifery. This is critical because, while steps are now being taken to increase the number of student midwives, the potential positive impact of this is undermined, as my noble friend has said, by too many experienced midwives leaving. Why? It is because they are burned out, insufficiently valued or rewarded, and because they cannot deliver the quality of care they want. In addition, senior midwives are needed to provide oversight and leadership, but this essential career route means losing experienced midwives, which is having an impact on the ability to train student midwives on their NHS placements. Staffing ratios need to reflect the combination of experience and skills needed to deliver care successfully. Within the workforce planning now under way, what review of national staffing ratios is taking place to ensure that we have sufficient staffing and funding for the population that NHS England serves?

The “stark and sobering” truth is that, in recent years, our maternity services have got worse, not better. The Care Quality Commission’s latest maternity survey shows the decline in positive maternity experiences. Confidence and trust in staff delivering care, whether antenatal, in-hospital or postnatal, has fallen over the past five years. Staff availability, and communications and interactions with staff, require improvement. My noble friend highlighted the BBC report from last November, which analysed CQC data and found that 67% of England’s maternity units—more than two thirds—had been rated by the CQC as inadequate or requiring improvement, up from 55% in the previous year. The CQC describes the overall picture as

“one of a service and staff under huge pressure”.

That is a thunderclap of a warning from the regulator.

More recently, we have data showing that the maternal mortality rate in the UK has risen to levels not seen for a decade, and shocking inequalities are contained within these figures. An investigation led by Oxford Population Health found that the maternal death rate was three times higher for black women than for white women, and two times higher for women from Asian ethnic backgrounds. Women living in the most deprived areas had a maternal mortality rate more than twice as high as those living in the least deprived areas.

Alongside the disturbing national data, we have seen catastrophic failings by specific NHS maternity units across England. The independent review of maternity services at the Nottingham University Hospitals NHS Trust is ongoing, while the investigations into maternity care at University Hospitals of Morecambe Bay NHS Foundation Trust, the Shrewsbury and Telford Hospital NHS Trust and the East Kent Hospitals University NHS Foundation Trust all produced recommendations for action, all prompting new oversight groups, strategies and targets.

We now have a national maternity safety ambition to halve the 2010 rates of stillbirths and neonatal and maternal deaths by 2025, which I understand we are not on target to achieve. Can the Minister confirm that? We have a women’s health strategy and the NHS long-term plan—and we finally have a Three Year Delivery Plan for Maternity and Neonatal Services, published in March last year. It sets out how the NHS will make maternity and neonatal care

“safer, more personalised, and more equitable” for women, babies and families. This is a great ambition—an essential ambition—but where are the building blocks that are needed to achieve it and overcome the stark data I quoted earlier? It seems to me that we have some way to go for this ambition to become a reality.

Midwives who shared their experiences ahead of this debate tell me that they have lost patience with reports and reviews. They say it really is about the numbers: more midwives in the wards means better care for mothers and babies, fewer mistakes, a more positive and supportive culture for midwives to work in and more reasons to stay in the profession. “Invest in more staff as quickly as possible” is the message I received. As we have seen from some of the terrible failings in recent years, ensuring a culture that fosters openness and learning really matters. I was dismayed to find that a number of midwives were not prepared to talk to me because of the negative repercussions for colleagues who had previously spoken out. Donna Ockenden’s review of Shrewsbury and Telford Hospital NHS Trust maternity services, published in March 2022, puts it succinctly:

“Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe, and compassionate, maternity care locally and across England”.

I therefore ask the Minister: can he give us any new update on progress on the actions and recommendations in the NHS England Three Year Delivery Plan for Maternity and Neonatal Services? How are they ensuring that recommendations for action will be widely implemented in all maternity services across England? We need to know that we are moving forward. We must do better, and we must do so quickly.

Photo of Lord Patel Lord Patel Chair, Preterm Birth Committee, Chair, Preterm Birth Committee 12:24, 25 January 2024

My Lords, I thank the noble Baroness, Lady Taylor of Bolton, for initiating the debate today on maternity services in England—or should I say, as has already been mentioned, the woeful state of maternity services in England as evidenced by a series of recent reports on their failings. Although we are debating maternity services, what we are really talking about is the state of care the nation is willing to provide for the mothers of the nation and their babies—the future citizens who will shape our nation.

I should say at the outset that I am well aware that good quality maternity services depend on the care and expertise that the key profession—midwives—provides. The rest of us, including obstetricians like me, are there to support them. I therefore fully subscribe to all the comments made about shortages of midwives and the quality of midwife care.

Before I go any further, I need to declare my interest: I am a lifelong obstetrician. I spent 37 years of my working life being one, and every minute of it was a joy and a pleasure. I would go back to it tomorrow if they let me—but they will not. I am also a fellow of several Royal Colleges, but that is totally irrelevant.

I am pleased to take this opportunity to put on record my eternal gratitude to all the thousands of mothers who afforded me the privilege of being a part of their lives at the most important time of their lives: during their pregnancy and the birth of their baby. I learned that pregnancy and childbirth give a whole new meaning to the word “beautiful”.

I had a special interest in looking after mothers who had preexisting conditions that could affect their pregnancy and the unborn baby, or who developed complications that may have threatened their pregnancy and the life of their baby. I was privileged to be able to do so. Understandably, these mothers were anxious and hoped all would go well. I remember one occasion when I delivered the healthy baby of a first-time mother who had diabetes and had had quite a challenging time during her pregnancy, to say the least. I noticed the pleasure on her face—I have seen it a thousand times; it is quite remarkable when a mother sees her baby for the first time—and I asked her how she felt. After thinking for a minute, she said: “I know the days will be shorter and the nights longer; clothes will be shabbier, but the future will be happier. I will forget the past. The baby will make love stronger. I was a woman yesterday; I am a mother today”. I will never forget that. To witness the joy in her face was a privilege. Sadly, according to recent reports, this is not the case for hundreds, if not thousands, of mothers. It should not be so. We should be ashamed that it is so for even one mother—but it is so for thousands, according to the reports already mentioned.

I was fortunate to be part of a team of professionals—midwives, obstetricians, anaesthetists, neonatologists and others—who were all committed to providing the best possible personalised care to all mothers and their babies. We never lost a mother in three decades, and had zero tolerance to intrapartum stillbirths. Weekly perinatal meetings were mandatory for all to attend to make sure that adverse events were fully discussed, learned from and never repeated.

The Government believe, as was noted by the noble Baroness, Lady Cumberlege, that the NHS is one of the safest places in the world to give birth. Minister, it was. In the past, our maternity services were where others came to learn. Why were our maternity units regarded as the best? It was because, as now, dedicated professionals provided safe, compassionate care to mothers and their babies, and took pride in doing so; and, importantly, they were left alone to get on with it.

Multiple reports from the CQC, as has already been mentioned, and independent investigations into several maternity units in England have shown that care is not safe, resulting in unacceptably high levels of harm to mothers and their babies. We all know that there are more such reports to come. While workforce shortages, pressures of work, lack of communication, and poor governance are all cited as possible problems, and they undoubtably are and need to be addressed, I believe that the genesis of the long-standing problems is deeper and goes further back. Therefore, I support absolutely the plea made by the noble Baroness, Lady Cumberlege, for a new beginning for maternity services.

The response from the Government and organisations responsible for the delivery of maternity services to adverse reports is to produce more documents about what they will do—set up a task force, a workforce plan that may deliver in five or 10 years, safety organisations, three-year plans, long-term plans, and much more. These lack implementation plans or regular outputs to demonstrate success.

The quality of maternity services is a bellwether for the quality of services in the rest of the NHS. Levels of maternal and perinatal deaths are good indicators of the quality of maternity services, as evidenced by several of the investigations. In this respect, as has already been mentioned, the latest maternal mortality report is a cause for concern in many ways. Confidential inquiries into maternal deaths were formally established in 1954, although their predecessor existed from 1928: it is the world’s longest-running successful audit system of healthcare and is a good barometer of the performance of the maternity service.

As has been mentioned, the latest report from MBRRACE of deaths between January 2020 and December 2022 shows that the rate of maternal deaths was 13.41 deaths per 100,000 maternities. That is the highest in the last two decades and much higher than the rate of 8.79 among the 2017-2019 cohort. Even after removing deaths due to Covid-19, the rate is significantly higher than among that cohort. The UK now has one of the highest maternal mortality rates in the developed world, compared with Norway’s 2.79, Germany’s 4.0—which, by the way, has remained static for 20 years—and France’s 6.0. We are way behind.

The main causes are important. The first is thromboembolic disease. We require a clear strategy for how we are going to reduce this, because it has remained the number one cause now for decades. I urge the professionals—the Royal College of Midwives and the general practitioners, obstetricians and psychiatrists—to come together to produce clear guidelines on how these deaths will be reduced. The second is cardiac disease. These deaths are preventable. Third, importantly and very tragically, are suicide deaths. These are vulnerable women whose mental health condition is not difficult to recognise during the antenatal period. They are women who might be abused in the house; women who are further abused when they take home a baby. We should not, as a society or as professionals, fail them, but we do. These 39 suicide deaths are tragic deaths: all maternal deaths are tragic, but these are particularly so. They are preventable and we should address that.

Maternal deaths also show up gross inequalities related to ethnicity and deprivation, as has already been mentioned several times. Black mothers have four times the risk, Asian mothers have twice the risk and mothers from deprived populations have twice the risk. These are not new or surprise findings, as mentioned by the noble Baroness, Lady Taylor of Bolton: inequalities in care and outcomes have been well documented for a long time. The Government have produced plans to try to reduce these, but none has shown any results. Can the Minister say which of the plethora of initiatives to reduce harm, deaths and inequalities in maternal health have had any effect? What benefits have been derived from the work of the Maternity Inequalities Oversight Forum, the Maternity and Neonatal Care National Oversight Group, the Maternity Disparities Taskforce, or the several other initiatives, in reducing inequalities and the deaths of mothers and babies and improving maternity services?

What we do have are repeated reports of high-profile organisational failures, soaring clinical negligence claims, huge variations in outcomes and in the culture of care, workforce challenges, inequalities in care and outcomes linked to ethnicity and depravation, rising maternal and perinatal deaths, and serious safety issues, to the point that the regulator, the CQC, says that England’s maternity units currently have the poorest safety ratings of any hospital services it inspects. Does this not all add up to a service that needs radical reform? Is it not time we had a root-and-branch independent review of maternity services that brings about the changes needed to have a world-class service that is compassionate, safe and delivers world-leading outcomes for mothers and babies? Can the Minister say why we should not have such a review, as part of his answer as to what difference all the initiatives so far have made to improve the service, with real figures to demonstrate it? I know he is fond of data as evidence.

Photo of Baroness Armstrong of Hill Top Baroness Armstrong of Hill Top Labour 12:36, 25 January 2024

My Lords, I enter this debate with some trepidation, having heard contributions such as the last from such a distinguished obstetrician, but I thank my noble friend Lady Taylor for introducing the debate.

I echo what the noble Lord, Lord Patel, said: what happens in maternity services should be seen as a bellwether for the rest of the NHS. The CQC reports on maternity services that Members have referred to are really quite shocking. We know that for women who are pregnant, this period forms their view of the confidence they can have in the services that they are relying on during pregnancy. There is more than one: it is not just a midwife, it is the GP, it is whoever they see in community services, it is all the other services that prop up their eventual delivery, and the post-delivery services, that are under the microscope here. During my period of chairing the Public Services Select Committee in this House, in virtually every inquiry, we came across women who felt that their relationship had almost been defined by this during their pregnancy: if it had been a poor experience, that introduced anxiety, concern and just a little trepidation about how they would make sure that their health and that of their family was looked after in future. I wanted to intervene in this debate to tease that out a little more.

I thank all the myriad organisations which have written to us about this debate, but also the Library. We are really privileged to have such high-quality research and attention paid to us. Too often, we take it for granted and forget to say thank you to the Library staff for doing that.

All the reports and briefings highlighted staffing and leadership, as the Public Services Committee did. For me, they underpin this whole thing. There is a crisis in staffing and in the skills mix there needs to be to ensure a happy and successful pregnancy for mother and baby, and there is certainly a crisis in leadership. Far too many of the good leaders have left, partly over Covid and partly because of additional pressures. The workforce plan on its own is not the answer. As the noble Lord, Lord Patel, said, you can have plan after plan and review after review, but without adequate implementation they will be just glorified bits of paper on the shelf.

I know well the chief executive of the Maternal Mental Health Alliance, because I worked with her in a charity that I chaired before she took up this role. I have heard from her over the past two to three years about the challenges in this area. I thank her team for their work and their briefing, from which I have benefited over many months rather than just for this debate. They are now working much more on the inequalities highlighted by most speakers today. In the Public Services Committee, we looked at what Covid revealed about our public services. It was absolutely clear that virtually none of them had understood the depth of the inequalities in how they responded to different racial and ethnic groups in our society.

We still have not got hold of what we need to do there. As the Minister knows, I have been anxious about this in terms of our preparation and trials of vaccines and how far they include ethnic minorities, because there are different genetic and cultural needs. Unless the workforce is sensitive and knowledgeable about that—practitioners must be enabled to be aware of it through their education and training, so that they can be sensitive to it when they are working with women from different cultural or ethnic backgrounds from their own—inequalities will be virtually inevitable. The Government have not been significantly sensitive to that in their approach, and that really concerns me.

Others have mentioned the stark reports from Embrace UK, which talk about not just the numbers but the effect on the women of their experiences. Others have talked about the numbers so I will keep my bit short, but, in looking at the care of black and white women whose babies have died, Embrace UK says:

“In around 1 in 2 baby deaths, the care assessed was poor. If care had been better it may have prevented the baby from dying … For around 3 in 5 mothers, care after their baby died was assessed as poor. If it had been better, it may have meant bereaved mothers were likely to have been better supported in their physical and emotional health”.

For both white women and black women—I will leave Asian mothers to the noble Baroness, Lady Gohir, as I am sure she will speak about them—the report assessed their care as good in only around one in five of the deaths reviewed. This is about basic care, not necessarily medical knowledge. Honestly, I am ashamed that we cannot do better and support our workforce so that it does better. Those disparities are huge.

On attitudes, another charity, Five X More, identified that the use of offensive and racially discriminatory language and being dismissive of their concerns was too often the experience of black, Asian and minority-ethnic women. Significantly, there was also a poor understanding of the anatomy and physiology of black women and of the clinical presentation of conditions in babies of black women. Then there were the racially based assumptions about the pain tolerance, education levels and relational status of black women. These are all issues in the basic care and attitudes experienced.

Most shockingly, mental ill health is the most common complication of pregnancy in the UK. At least one in five women experiences a mental health problem during pregnancy and after birth, and suicide is the leading cause of maternal death in the post-natal period. Again, this is honestly shocking. We need to be able to intervene much more appropriately. Midwives are ideally placed to ask sensitively about mental health in their routine contacts with women, but too often that simply does not happen.

Again, I come back to the fact that this is the time in women’s lives when they will have the most interactions with healthcare professionals, so it is the time to make sure that mental health becomes a normal way of working with women when they present to healthcare professionals—I do not see pregnancy as an illness—in whatever sense. Attention to mental health must be part of how they are handled.

I am really trying to say that there are lots of things that we know the Government must do. They need to get on and do them rather than continually doing reviews. Here I disagree with some other speakers; we need to get on and improve the services in the way that so many of us have been told they need improving.

Photo of Baroness Watkins of Tavistock Baroness Watkins of Tavistock Deputy Chairman of Committees 12:48, 25 January 2024

My Lords, I draw attention to my registered interests in healthcare. I thank the noble Baroness, Lady Taylor, for bringing this important debate to the Chamber. Her speech was an absolutely laser-focused analysis of the current situation and summarised many of the issues that I will return to—without, I hope, too much repetition.

The current state of maternity services in England is of concern to many stakeholders, but this must be put in context. Most expectant mothers and their significant others receive high-quality care during pregnancy and are delivered of healthy babies. However, the latest CQC report rates 10% of maternity services as inadequate and 39% as requiring improvement. This margin of error in such a vital service is really concerning.

Shockingly, safety and leadership remain particular areas of concern, with 15% of services rated as inadequate for safety and 12% rated as inadequate for being well led. I think we can all agree that this is an unacceptable failure of the women, their partners and babies in this country. Of particular note is the fact that poor provision is disproportionately failing many mothers form minority-ethnic groups, as others have outlined, but also white women who suffer economic deprivation.

Many factors contribute to this situation. Part of it might be that there has been less regard for the profession in the last decade than there was. I remember coming to the end of my general nurse training, just 500 yards down the road, and being asked what I was going to do next. I said I wanted to do mental health nursing, and I still remember the sister tutor saying to me, “But you’re bright enough to be a midwife”. We should hold on to that. I am happy to tell you that I got an obstetrics certificate so that I could work abroad and ended up as a mental health sister with a mother and baby unit in that ward—so I actually used it wisely.

Midwives are now men and women, and we do not seem to have recognised that in some of our structures in multidisciplinary teams. With men, we hoped that it would improve the provision of employment for midwives, as well as double the amount of people from whom we could recruit the pool. That does not actually seem to be working as well as we might have hoped.

Quite frankly, most multidisciplinary teams face large, unmanageable caseloads, and have to work with what—in some areas—are unsafe staffing ratios. To my mind, they often do not receive fair compensation for their important work. As commended by the CQC 2023 report, midwives and staff on maternity wards go above and beyond, when possible, to provide the best care.

However, services are being pushed to breaking point. As has already been acknowledged, it is estimated by the Royal College of Midwives that we have 2,500 full-time vacancies. This obviously leads to overload and understaffing in some areas, and the quality of care provided is put under threat. This is recognised in the 2023 NHS England Three Year Delivery Plan for Maternity and Neonatal Services, which highlights that supporting the workforce to develop skills and extra capacity is vital to providing future high-quality care.

I want to put this in context. When I went off to do mental health nursing as a second qualification, I was paid as a staff nurse. Now, it is almost impossible to get a second qualification without going back on a bursary. I will leave that for people to think about. I therefore support the commitments that have been made to ensure that trusts will meet staffing levels and achieve full rates for midwifery by 2027-28. However, it remains very difficult for a registered nurse to do a shortened course to become a midwife. I therefore suggest that women will continue to face what some do now: hurried care with staff having little time to provide truly person-centred support.

Like many other contributors to today’s debate, I have my own children and know that good health during pregnancy and labour and postnatally is vital. So is good healthcare. If you do not start with good health and then have poor healthcare, that is a pretty difficult situation. Staff need time to listen to mothers and fathers and to act when concerns are identified. As I have told this House before, with my first child, I felt ill. My husband came to visit me in the hospital the day she was born. I do not remember this, but apparently I grabbed his hand and said, “You will look after this baby if I die?” Then he realised he should go and talk to somebody, because this was not the way I normally talked about things. I had fantastic, fast intervention and had my baby within half an hour—who I am pleased to tell you is now a taxpayer. That was a good, cost-effective solution, but too often people do not listen to significant others, who sometimes understand very well what mothers are saying. We therefore cannot rest the whole responsibility on the mother in a time of distress.

It is necessary to think seriously about access to interpreters on a 24-hour rota system, so that women who are unable to speak or understand English because it is not their first language can be assisted in communicating with the staff caring for them. We have situations in some areas in which it is impossible to get an interpreter. That makes the situation really difficult, both for the midwives and for the mother. One cannot always rely ad hoc on a relation interpreting what is really going on. Can the Minister comment on how access to interpreters is monitored within the NHS and, if this is not being undertaken, can he ask the Government to make provision to do so? I have been informed that this is particularly important in genetic counselling in families from cultures that are different from those of the midwives involved.

Staff are often unhappy due to pressure at work, in part associated with low levels of staffing. As other noble Lords have said, it is also because senior midwives are retiring or retiring earlier than planned, for a variety of reasons. Many who are leaving are specialist mid-career midwives, whose skill set cannot be easily replaced, particularly in terms of supervising student midwives. I am really proud that the daughter who is the taxpayer is a teacher. However, teachers get rewarded on top of their salaries for supporting student teachers if they are the lead in it. This is an example of something we could learn from.

In part, retention issues reportedly stem from inflexible working practices. Flexible working is difficult to manage in a 24-hour, seven-day service. I know; I have tried it. However, some trusts have much better retention than others. How can best practice be shared and replicated to retain midwives across the NHS services?

The stress of unmanageable expectations at work is creating burnout, as some others have reported, and encouraging some midwives to leave the profession. Perhaps we should think about a structure for sabbaticals for some midwives. Midwifery is, at the best of times, hard physical and emotional labour. We do not always recognise that. When things go well you get the rewards but, as my noble friend Lord Patel has just spoken about, when things go badly it can be devastating.

Capacity is being undermined by a lack of investment in continual staff development. This is highly worrying because, as others have said, we face an increase in complex births, as more women are giving birth over the age of 35—as I did—maternal diabetes has increased, the use of induction and caesarean has increased, and pre-term births are becoming more common. These cases require specialist skills so that mothers and babies are safe. However, a lack of training and development opportunities for midwives, both men and women, can lead to a deficit of skills that are vitally needed for our specialist services to survive in the future. Midwives need to be skilled at recognising complications in pregnancy, ensuring that they pass those to other members of the multidisciplinary team for assessment, so that, wherever possible, early intervention can be undertaken.

The vast majority of our student midwives in England report having to take on additional debt, over and above the loans available to students, to cover their basic costs. This is undoubtedly putting people off coming into midwifery. The National Union of Students reported a worrying drop in applications to university courses, from 13,500 in 2021 to just over 10,000 in 2023. Can the Minister say whether the Government will consider the NHS undertaking loan repayments for university fees after, say, three or five years of NHS service? It would aid the retention of midwives, nurses and indeed junior doctors, as well as other professions allied to medicine.

Our midwives work tirelessly to provide the best care they can, but they are often unable to do so because of the issues highlighted by other noble Lords and in my own contribution. We must ensure that these issues are tackled, so that every woman is provided with truly person-centred, skilled and compassionate care, and that all babies have the best possible start. The Royal College of Nursing has produced nursing workforce standards that could apply to paediatric intensive care units. Similarly, the Royal College of Midwives has provided evidence on the necessary ratios of midwives to expectant mothers at differing stages of pregnancy. Are this Government prepared to consider legislation on workforce standards in the NHS in future?

Photo of Baroness Donaghy Baroness Donaghy Labour 1:01, 25 January 2024

My Lords, I thank my noble friend Lady Taylor for initiating this debate with her usual thoroughness and elegance. If the recommendations made by the noble Baroness, Lady Cumberlege, were all implemented, we could go home now. The noble Lord, Lord Patel, nearly made me cry. This is a very important subject, and I am glad that it is being debated. I hope that, even with all the other difficulties that the health service is faced with, the Minister will take on board the vast experience in this Chamber on this subject.

When I was a non-executive director at King’s College Hospital NHS Foundation Trust, we were fortunate to have Cathy Warwick as the lead for maternity services. Directors were kept well informed about what was happening, but I understand from various CQC reports that that good practice does not exist.

I will cover items about the pay structure and about those who experience birth trauma of a severe kind—as well as a little about the deterioration in maternity care; but that has been well covered, so I will reduce that section of my speech.

I believe that the NHS pay dispute was avoidable. The origins go back to the clumsy and arrogant stance taken by previous Health Secretaries. One Health Secretary took the junior doctors on some years ago and beat them. Ministerial memories may be short, but junior doctors have longer memories. Whether they are badly led or well led does not matter; the strength of feeling is still there.

I will refer to the Government’s consultation on creating a new pay scale for nurses and midwives. Having had experience of this, I would caution the Government against any separation for a number of reasons. The Agenda for Change pay structure, carefully negotiated over a long period of time, is underpinned by the NHS job evaluation scheme, which determines the levels at which all healthcare professionals are paid. A separation of the nurses’ pay structure would divide and rule, which is irresponsible in the long term. It would not lead to more money or more midwives, it would not help with the chronic retention problem and, most importantly, it will lead to equal pay claims and a serious risk of unplanned extra costs.

That is not a theoretical view. When I first arrived at ACAS, I was faced with over 500 equal pay claims from ACAS staff. It caused a great deal of amusement from my previous TUC General Council colleagues when they heard I got the job of chair. This was in the days of a Labour Government, so I am not making a party-political point on the subject of pay structures. The problem arose because of the break-up of the Civil Service negotiating structure and the separation of grading by government departments and non-departmental public bodies. ACAS, as an organisation, given the problem of 500 equal pay claims, was faced with sclerosis and low staff morale and risked being a laughing stock, because it was supposed to solve employment relations problems, not be the centre of them.

It was clearly a priority for the ACAS council and the new chief executive to solve. I will not go into the details of how it was done—why give away trade secrets?—but it cost us £10 million. We were given the money by government, but exactly the same amount was taken off us the following year. Subsequent redundancies cost us hundreds of staff and thousands of years of experience. Compared with the number of nurses and midwives, that cost is small beer. I urge the Government to think very carefully before they leave such chaos behind.

The Minister will no doubt be aware of the All-Party Parliamentary Group on Birth Trauma and its recent launch of a parliamentary inquiry on birth trauma. It is co-chaired by Rosie Duffield MP and Theo Clarke MP, and will be assisted by the charity Birth Trauma Association. Its stated aim is to collect evidence so that government can take practical and achievable steps to improve care and support for new mothers and their partners, and incorporate birth trauma into the women’s health strategy. The stories told by some women of their experience are horrifying, and the physical and mental trauma suffered by some are often unrecognised by the very professionals who should know better.

A relative of mine gave birth to two children and the effect on her was shattering. Her mental health did not recover for two decades. She spent months in a mental health institution after each birth. This might have happened under any circumstances, but recognition of the dangers, and the right information and preparation, might have led to a different outcome.

Recent CQC inspections reveal that maternity units are failing women; the figures have already been stated. According to the Birth Trauma Association, some women who have had a dreadful experience find that they are not listened to. They say that complaints are met with attempts to minimise the women’s trauma and deny responsibility. Frequently, the BTA was the first organisation to listen to women’s accounts and acknowledge their trauma.

A common feature is the failure to acknowledge pain levels. In a recent television drama series, two of the regular male doctor characters were challenged to take a test to experience similar levels of pain to those experienced by women in childbirth. The test went from “mild” to “severe”, and they were only half way up the painometer before they pleaded for it to stop. I know that it was a drama—although we have learned how powerful dramas can be, in different circumstances—but it clearly illustrated a point that women have been making for centuries. I should add: please do not try this at home. Will the Minister ensure that his department studies the results of the APPG inquiry when it is published and take steps to improve things?

Finally, the CQC’s 2022 maternity survey, designed to assess the quality and safety of maternity services in England, received over 20,000 responses. They showed that experiences of maternity care have, as has been said, deteriorated, particularly over the last five years. The issues of availability of staff, confidence and trust, and communications and interactions with staff have already been outlined.

I should emphasise, as did the noble Baroness, Lady Cumberlege, that the majority of respondents were satisfied, but sometimes it is now a very narrow majority. For instance, in-hospital care after birth showed that a worrying 57% of respondents said they were always able to get help, while, as my noble friend Lady Warwick said—she has already mentioned the shortage of 2,500 midwives—the Royal College of Midwives has described the impact of staff shortages on women as “stark and sobering”.

Up to now, the Government have said that they have no plans to commission a public inquiry into the future of maternity services, despite the fact that it has been suggested by the Maternity Safety Alliance and Mumsnet. Can the Minister say in what circumstances the Government would change their mind about a public inquiry?

Photo of Baroness Gohir Baroness Gohir Crossbench 1:10, 25 January 2024

My Lords, I declare my interests as set out in the register, in particular that I am the CEO of the Muslim Women’s Network UK. In that role, I published a maternity report, Invisible: Maternity Experiences of Muslim Women from Racialised Minority Communities, in 2022. I thank the noble Baroness, Lady Taylor of Bolton, for securing this important debate because, despite the many research reports and inquiries that we have had, we are still waiting for a step change in the improvement of maternity care. I will focus my comments mostly on maternity disparities for minority-ethnic women, data training and accountability.

Data is crucial to really understand inequalities. However, when maternity data is often broken down by ethnicity, it is usually done so into broad groups such as black, Asian and white, which masks the inequalities among different subgroups; they then remain invisible and continue to have poor outcomes. For example, Arab women are rarely spoken about but the research that I conducted found that they have poor outcomes compared with other minority-ethnic groups. In the south Asian group, Bangladeshi women tend to have the poorest outcomes. Among black women, I found that black African women and mixed-race women tend to have the poorest outcomes.

I also have concerns about poor outcomes for women from, for example, eastern European backgrounds, so it is also important to break down the white group further. In this group, women with lower educational levels, single mothers and very young mothers—in other words, women who have less of a voice—are also likely to have poorer outcomes. Can the Minister say when the Government will have a detailed strategy that responds to the inequality experienced by each group?

One way of responding to inequalities more quickly rather than just waiting for datasets, which can take time to produce and analyse, is to use feedback from the complaints system. However, research—even hospital complaints data—often shows that there is a low level of complaints from particular groups, certainly minority-ethnic ones. Can the Minister say what action the Government are taking to ensure that families are aware of the complaints procedures? How will they have confidence in that service?

Given the poor experiences of minority-ethnic women, one would expect them to be overrepresented in maternity litigation data, which would help to indicate where the risks are for them. If they are underrepresented, it would indicate that they are not being compensated for the harms that are being caused to them. I decided to investigate this issue during my research so I put in a freedom of information request to NHS Resolution, the body that deals with claims of compensation on behalf of NHS England and which apparently works to resolve concerns and share learning and improvement. I was shocked to receive the following response in 2021:

“In terms of ethnicity breakdown, this information is not held as it is not recorded in our claims management system”.

This was astonishing given that ethnicity data is routinely collected by the NHS and is crucial for identifying inequalities between different groups. This is perhaps one of the clearest examples of systemic discrimination by the NHS.

I have since had letter exchanges with the CEO of NHS Resolution and asked for ethnicity data to be recorded. The response has been positive: I have been told that the data management systems are being upgraded now to record all protected characteristics. I have been informed that it may be a voluntary option, however, which is likely to result in low data capture. Yet this data can be pulled in from hospital records; it is routinely collected. I have also been informed that data and trends will be shared only internally for learning, so how will the public identify trends and hold the NHS to account?

I ask for assurances from the Minister. Will he ensure that NHS Resolution collects protected characteristic data from the hospital management systems, rather than on a voluntary basis, and that this information is made available to the public? This would help identify inequality among different groups for all types of medical negligence claims, not just maternity claims.

Next, on training, although workforce shortages will no doubt contribute to poor healthcare staff attitudes and poor maternity care, many maternity research report findings provide clear evidence that there exists among some midwives and obstetricians a culture of being desensitised to women’s pain and of having negative attitudes towards women, which is even more pronounced for women from racialised minority communities. How do the Government plan to address the issue of patient engagement and cultural competency training? Having served on a hospital board, I know that, if a maternity ward is short-staffed, staff will not have the time to undergo such training. Also, the UK has large numbers of doctors and nurses recruited from abroad. Their culture of patient care is likely to be different. Here I refer to non-medical aspects of patient care. Does the Minister agree that some kind of approved patient communication training should be mandatory for recruits from abroad?

Finally, have the Government pulled together the many recommendations made by numerous maternity reports, such as those from Birthrights and Five X More—including the one that I authored—to ensure that the recommendations are being implemented? The Government’s women’s health strategy does not adequately deal with many health inequalities for women—minority-ethnic women in particular—including maternity disparities. More needs to be done there; the strategy needs to be strengthened. I therefore urge the Government to appoint an independent maternity commissioner from outside the NHS to provide scrutiny and hold all agencies to account, which would benefit all women. We have commissioners for many other areas. In maternity services, too many babies and mothers are dying or ending up with poor outcomes, which can have lifelong consequences. Will the Minister agree to the appointment of a maternity commissioner?

Photo of Baroness Bennett of Manor Castle Baroness Bennett of Manor Castle Green 1:18, 25 January 2024

My Lords, it is a pleasure to follow the important speech of the noble Baroness, Lady Gohir. Her words reflect what I heard last night at a meeting with Justice for Windrush Generations, where there was a reflection that minoritised communities share the experience of inequality and discrimination but the individual experience of different communities is different and needs to be acknowledged.

I thank the noble Baroness, Lady Taylor of Bolton, for securing this debate and reminding me of a meeting that I attended in Huddersfield in 2016. It had 480 people stretched across two meeting rooms with hundreds of people outside, unable to get into the room. It was the “Hands Off Huddersfield Royal Infirmary” campaign. I note in looking around today that a book recounting that campaign, Fighting from the Heart by Cormac Kelly, has just come out. It will pick up one of the themes of my speech: we have rightly been focusing on listening to individual patients but we also need to listen to communities and the demands that they make of their maternity services. The case of what has happened with Huddersfield Royal Infirmary is an example of that.

I am perhaps quite unusual in this debate in that I bring neither personal nor professional experience, so I put the topic out around the Green Party to collect people’s views and experiences. One that came back shocked me a little, and I will anonymise it because I am referring to a member of staff. This member of staff reflected on her personal experience. She was a professional woman in London, so you would have expected her to be well equipped to navigate the system, but her experience was that she did not have the NICE-recommended number of antenatal appointments and, as a result, a serious issue was missed. That reflects on an individual level what we are hearing from all the royal colleges et cetera about the inadequacy of services in all the statistics.

Coming back to the community point, a Green Party Birkenhead and Tranmere councillor, Amanda Onwuemene, who is herself a former midwife, drew my attention to the current perilous situation of the Liverpool Women’s Hospital, which is threatened with closure. The alternative accommodation and services being proposed do not match those being lost in maternity and other services, and the NHS and the women of Merseyside are being shortchanged again.

I want to look at what is happening there because it is a reflection of something we have not talked about very much: the issue of private finance initiatives, the privatisation of the NHS and how it has cut away at resources. That is reflected in what is happening in Liverpool and other places. The concern is that a particular quality of service is at risk of being lost.

That is also reflected in what is happening in London, where NHS North Central London is consulting on the potential of closing one of two maternity services in London hospitals due to fewer births. These are the Whittington and the Royal Free. If someone from outside London looks at a map, they might look at those two and think that they are not too far apart, but anyone who knows this area—and I do well from previous political campaigning—will know that the public transport provision heading east-west across London is extremely poor. People frequently have to take three buses to get from the east of what is the Whittington’s catchment area to the Royal Free, and people need local services and that is something that really must not be lost. I quote Mayani Muthuveloe from Whittington Maternity and Neonatal Voices, who told BBC London that there was a real “sense of reassurance” from giving birth in hospital near to where family and friends live, and that travelling to a facility further away would “add pressure” on patients.

We are seeing not just overall quality of service issues, but an issue of loss of local services. It is worth contrasting this with the Government’s own words in commenting this month on the women’s health strategy for England. That is focused on expanding women’s health hubs and, rightly, on maternity care,

“continuing to deliver on NHS England’s 3-year delivery plan for maternity and neonatal services”.

So the Government have plans for this, but, as we have heard from so many noble Lords, we are not seeing the outcomes that we desperately need.

I will pick up some points made by the noble Baroness, Lady Gohir, because the figures are deeply shocking. These are grouped figures, because those are what the NHS provides, but I am relying in part on the briefing from the Royal College of Obstetricians and Gynaecologists. Women from black ethnic backgrounds were three times more likely to die during or up to six weeks after pregnancy, and Asian women twice as likely. Deaths from mental health-related causes, as many noble Lords have highlighted, account for nearly 40% of the deaths occurring within the year of an end of pregnancy. I have a direct question here. Will the Government, as the royal college is calling for, commit to a time-limited target to reduce maternal inequalities to drive the innovation, improvement and, crucially, investment that is needed in these areas?

I will briefly pick up a point made by the noble Baroness, Lady Watkins, because I think it is terribly important. There is no doubt that the serious, major issues we are seeing in the outcomes of maternity services reflect more broadly the poor level of public health across our entire population. This is where I run into the Green Party problem, which is that everything is related to everything else. When you bring systems thinking in, you need to think and talk about everything. When we are talking about maternal health, we have to talk about people’s working hours and commuting time. Are people able to work from home? Do people get the breaks and the kinds of working conditions they need to have a healthy pregnancy and birth and to provide healthy care for their baby?

I was looking at a really interesting study from the University of Swansea about how, counterintuitively, during the biggest period of lockdown during the pandemic, when there were real shortages in the provision of services—probably unavoidably—in Wales, they found that rates of breastfeeding, successful breastfeeding and length of breastfeeding actually went up. This is where we need to look at that social setting. If people are able to work from home, if they are at home and if they have less commuting time and are able to spend more time with a newborn, you end up with healthier outcomes. While we have to acknowledge that breastfeeding cannot and will not work for everybody, we all know that it is crucial for the health outcomes of both mothers and babies to encourage that as much as we can.

I am sure that pretty well all noble Lords have received the perhaps predictable but important flood of briefings before this debate from Mumsnet, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, to which I have already referred, Baby Lifeline, Sands and the Care Quality Commission itself. They all stress the huge problems with the workforce, particularly people not being trained or having to be trained under conditions of extreme debt and, of course, the number leaving the professions, particularly midwives.

I am reminded of a trainee midwife who I spoke to just as the change was being made that midwives would be loaded down with debt through having to pay for their own training. She was, as is often the case, doing a second degree. She had done one degree, had worked, had a couple of children and decided to retrain as a midwife. She was speaking of her experience of being a trainee midwife in a birth suite where, tragically, there had been an unexpected stillbirth. It happened that all the fully qualified professionals in that room were occupied with medical things and she found herself comforting the mother who had just had an unexpected stillbirth. I find it obscene that people are now having to pay fees to be doing something like that as they are completing their training. I do not think that is acceptable.

I have some more on the debt point. These figures are from the Royal College of Midwives. Three-quarters of the student midwives in England surveyed expect to graduate with debts of more than £40,000. Just 1% expect to graduate with less than £5,000 of debt. About half—47% of all student midwives in England—have a job outside their training in order to earn money, and that job is unsurprisingly having a negative impact on their training. That cannot be acceptable. It cannot set people up for a long-term, secure, stable career in midwifery. I am referring here to the Sands briefing, which states that the lack of staff puts more pressure on the existing staff, so more people leave, and then the lack of staff puts more pressure on. It cites a midwife, who says:

“Staff are frightened to work in an understaffed under-resourced unit, for fear of mistakes or incidents occurring due to the high activity and understaffing. Fear of investigations as a consequence and fear for their mental health and wellbeing as a result”.

This is what we are doing to our midwives.

I have one financial point to make, drawing on the Mumsnet briefing. The Government paid out £2.6 billion in the past year as a result of failures in maternity and neonatal care in the NHS. This is costing us enormously, including financially. Circling back to my initial point about the importance of local facilities, women’s facilities and listening to communities, I looked up Historic England, thinking about the situation in Liverpool. The first women’s hospitals appeared in the 1840s. There were 12 by 1871. Many people may know of the site, no longer there, where Elizabeth Garrett Anderson founded the New Hospital for Women, London, on the Euston Road. We have been through several cycles. In early modern times we had female midwives who, by the standards of the time, provided good-quality care. We then saw the arrival of male midwives, which actually saw more deaths. Then in Victorian times we saw the upswelling of women’s services. We are now at risk of losing them again. This is a cycle we need to break.

Photo of Baroness Thornton Baroness Thornton Shadow Spokesperson (Equalities and Women's Issues), Shadow Spokesperson (Culture, Media and Sport) 1:30, 25 January 2024

My Lords, it is a great pleasure to be taking part in this debate, and I thank my noble friend for her balanced introduction. I declare an interests as the maternity safeguarding non-executive member of the Whittington Hospital board and, of course, my day job as the shadow Women and Equalities Minister, both of which will inform my contribution today.

My life and possibly my son’s life might have been lost without maternity services when he was born 37 years ago at the Homerton University Hospital. I think he was the fifth baby born there—it was a brand new hospital—and the midwife and I were wandering around trying to work out where the light switches were. There is no doubt that they saved our lives; 100 years ago, we would both have died. We must recognise the great progress that has been made in antenatal and natal care in our NHS. I was particularly moved by the contribution of the noble Lord, Lord Patel, the importance of which is reflected in the Ockenden review and the need for multidisciplinary teams in our maternity units. We are talking about not just midwives but the role of people such as the noble Lord and our gynaecologists.

I meet amazing and dedicated midwives in the course of my work as a non-executive member of the Whittington Hospital board, and they are all too aware of the challenges they face, because there is a desperate need for more resources and better staffing. The Whittington is an old hospital. Some bits were built in Victorian times, including the entrance to our maternity unit, which might still have “lying-in” signposted on it. The noble Baroness, Lady Cumberlege, graciously opened a new birthing suite for us about a year ago and will bear testament to our having to adapt our facilities all the time.

One thing I am sure of is that a change in culture is still required in the NHS if it is to place the value on maternity services that it places on other medical services. I was conscious that maternity did not feature as often or as highly as it should have in our governance arrangements. It does now, but that is probably writ large in our hospitals right across England. As my noble friend Lady Taylor said, the core of the challenges outlined by the Ockenden and CQC reports is staffing. In its briefing, the Royal College of Midwives notes all the relevant points: 2,500 midwives are missing, we need to improve retention of experienced midwifery staff and increase the number of newly qualified midwives, and we need to place real value on our existing maternity services. There is no doubt that some maternity services have failed women and families. It is important that those lessons are learned and that we ensure that those mistakes do not happen again.

We must eliminate the stark, persistent, unacceptable disparities in the maternity death rates suffered by black women, Asian women and women from some of our most deprived areas, as eloquently described by the noble Baroness, Lady Gohir. I agree with her about the need for collecting data. Having been involved in equalities work for a very long time—some 40 years—I know that if you do not monitor and do not have the data, you cannot know where discrimination is taking place or show where deeply rooted discrimination is embedded in our systems. You have to collect that data. This Government have not always done that, and occasionally they have stopped funding. They need to collect that data.

The Commons report on black maternal health was vital to this debate. I raised this with the then Minister, and we had an exchange about the root causes of black and ethnic minority mothers dying at a starkly higher rate than white women. We both agreed that it was partly embedded racism in our maternity delivery services, and partly socioeconomic reasons and deprivation in some of those communities. That does not mean that we do not need to address this. A report by the Muslim Women Network said that black Muslim women, especially black African women, were most likely to receive poorer standards of care, followed by south Asian women, particularly Bangladeshi women. The Commons report noted that the themes included—as the noble Baroness, Lady Gohir, said—a gap in data and information collection on the needs, experiences and outcomes of minority ethnic women; women not being listened to; and women receiving care that was neglectful and lacked dignity and respect. Those are some of the challenges we need to address in tackling the difference in mortality rates in our maternity services.

We also need to recognise that we must take urgent action to tackle what is acknowledged as systemic racism in UK maternity services. It is always hard to say that when you have worked in public life on equalities for as long as I have, but the noble Baroness, Lady Gohir, absolutely illustrated it. I am shocked. I did not know that we were not collecting data on the claims and financial implications of maternal and infant death.

I turn to a more positive story concerning working with a general integrated hospital at a local level, like my noble friend Lady Taylor. We are both from Yorkshire, and Bradford and Huddersfield are the hospitals with which I am familiar at home. We know that it is important that those hospitals respond to the needs of the populations they serve. As an adopted Londoner and a non-exec at the Whittington Hospital, I can tell the House that we have tried to address these issues in various ways. I want to mention some of them because they are important. We are a local general hospital slap-bang in the middle of the inner city, serving mostly the very mixed population of Islington and Haringey. By the way, I am particularly proud of the fact that during Covid, all our births were attended. We did not stop fathers and relatives being present at the birth of babies in our hospital.

The specialist services that our midwives offer have to reflect the needs of our local population. I am impressed—and I hope this will be a generalist remark—that, for the varying conditions presented by pregnant women, whether epilepsy, diabetes, bipolar or sickle cell, we have midwives who are specialists in those areas. They need to be, because these conditions would have been barriers to giving birth in the past or would have made it a very dangerous procedure. In our part of London, we have a sickle cell unit in our hospital—it is a generalist unit of which we are very proud, and it has this very specialist unit—and, of course, it works right across into our maternity unit. That is very important, because we have mums coming in who have sickle cell, with all the problems that that presents.

As mentioned by the noble Baroness, Lady Watkins, for instance, combining midwifery with other expertise and experience, particularly mental health services, is very important. A woman who has a serious mental health condition and is having medication for that will need to be carefully monitored right through her pregnancy. Those specialities are very important indeed, to say nothing of the fact that mental health problems can sometimes assert themselves anyway as a result of a pregnancy.

The second thing I want to talk about is female genital mutilation. As a local hospital, in 2000, we had to respond to the fact that we had a growing number of pregnant women presenting who had suffered female genital mutilation. So the Whittington Hospital now has a female genital mutilation clinic, which used to be known as the African Well Woman Clinic. It was established in 2000 by a woman called Joy Clarke. Today, that clinic provides services on FGM: counselling, antenatal care, assessment, de-infibulation—reversal of FGM—and post-surgery and postnatal follow-up. It provides that service not only in Islington and Haringey but to the whole of London, and women from all over the country come to avail themselves of those important services. The midwife who leads it is called Huda Mohamed. She trained as a midwife at the hospital, joined the FGM service in 2012 and became our FGM lead in 2016. It is such a highly regarded service nationally, and she has played such a crucial role in providing a comprehensive and holistic approach to managing and raising awareness of FGM and the significantly positive outcomes and benefits for women who have undergone this procedure. She was given an MBE in the New Year Honours List, and we are very proud of that.

Photo of Baroness Bull Baroness Bull Deputy Chairman of Committees 1:42, 25 January 2024

My Lords, like other noble Lords, I congratulate the noble Baroness, Lady Taylor of Bolton, on initiating this important debate and on her comprehensive introduction. It is a privilege—but, as has already been noted, somewhat daunting—to speak in this debate among so many acknowledged experts and long-standing contributors in this area.

The always excellent Lords Library briefing, already mentioned, highlights an issue raised by several noble Lords across the House: the experience of maternity services is not equal for everyone, and, once again, already marginalised communities and those in less privileged situations report a poorer experience of maternity services. I want to use this opportunity to highlight the experience of maternity services in England for another group who are not often included in these debates: women with learning disabilities.

The 2016 National Maternity Review set out NHS plans to improve maternity care and the care of people with learning disabilities. Despite this, the experience of maternity care for those women is still found to be consistently poorer than for the rest of the adult population.

A learning disability affects the ways in which people understand information, learn new skills and communicate. It may also mean a reduced ability to cope independently. Learning disabilities are often unique to the individual and can present in many forms, some obvious and some more covert in nature.

Of course, the general good principles of person-centred care apply to caring for people with a learning disability, but the challenges of pregnancy for women with learning disabilities, which include higher risks of perinatal complications and caesarean delivery, mean that midwives and other health professionals need particular skills and knowledge if they are to provide this person-centred care through pregnancy, childbirth and early parenthood. Without this specific skill set, the needs of these women cannot be met.

Significant emphasis needs to be placed on effective communication and the application of reasonable adjustments, to prepare parents and offer them practical and emotional support through their path to parenthood. People with a learning disability need to understand their midwife, and they need a midwife who understands their needs and knows how to provide the right support. That midwife may also need to educate and support other health and social care professionals they encounter on their journey to do the same.

The importance of continuity of care cannot be stressed highly enough when providing care to people with a learning disability. Equally important are the collaborative efforts of professionals to build a network of trust and care, which needs to be available through the parenthood journey, beyond birth, to best assist parents in bringing up their child and avoid those regrettable cases when children of parents with learning disabilities are removed from their parents’ care.

Public Health England’s 2016 recommendations and the Equality Act 2010 state clearly that people with learning disabilities should be provided with reasonable adjustments. If adjustments are not put in place to accommodate the complex and diverse needs of pregnant women with learning disabilities, they may be subject to a system that just does not work for them. One example is fast-paced appointments in which they are asked to absorb high levels of complex information and make informed choices at speed.

Writing in the British Journal of Midwifery in 2019, Samantha Vernon reported the findings of her research internship at the National Institute for Health Research into maternity services for people with learning disabilities. Her interest stemmed from her 19 years of clinical practice, in which she identified an increasing number of women with learning disabilities presenting for care in her trust but found no mention of learning disabilities in the 2019 NICE guidelines and no specific care pathway for women with learning disabilities.

Among her conclusions, she recommends the broader use of a “passport” for pregnant women with learning disabilities—a document prepared with the antenatal team that goes with these women through their maternity journey to help all the health professionals they encounter understand the ways in which that person’s learning disability affects their interactions with obstetrics and midwifery services. This would include critical information, including on reasonable adjustments, updated as appropriate, and would reduce the need for patients to be questioned over and over again, thereby reducing stress and saving NHS time. I know that hospital passports are now recognised for use by people with learning disabilities but it is not clear how actively they are promoted in maternity services. Perhaps the Minister could comment on that.

Samantha Vernon’s other key finding, perhaps unsurprisingly, is that formal training on learning disabilities needs to be increased so that health professionals can recognise and support women with learning disabilities through pregnancy, childbirth and early years care. This aligns with Mencap’s research, which uncovered a patchy picture in which the number of hours devoted to this content and the level to which this learning is assessed varies widely. Its 2017 Treat Me Well campaign showed that 69% of registered nurses wanted more training about learning disabilities. A qualitative study from Dr Emma Castell in 2016 found that midwifes often felt inadequately equipped with the necessary skills and training to care for women who have learning disabilities.

These studies are from some years back and there have clearly been some improvements in the intervening years. In January last year, working with NHS England and supported by the National Institute for Health and Care Research, the University of Surrey’s Together Project published a toolkit and guidelines to support the delivery of good practice in maternity services for parents with learning disabilities. This was based on existing research, best practice reviews and several interviews with health and social care professionals, parents with learning disabilities, and their supporters and carers. It is a clear and accessible guide, with practical and implementable evidence-based actions that can be taken. Can the Minister confirm whether this toolkit is widely available across all maternity services?

People with a learning disability—including those who are pregnant—are protected by a legal framework that entitles them to reasonable adjustments, so that they can access services; adjustments to communication; support with decision-making; the right to a family life; and dignity in care. Yet Mencap’s experience of providing training across several hospital trusts leads it to conclude that attitudes towards people with a learning disability can vary. It reports that, in some healthcare professions, including at senior levels, there are misunderstandings about what a learning disability is; lack of awareness about health inequalities; low awareness of the support required and the need to adapt communication; and a need for guidance on the implications of and responsibilities under relevant legislation, including deprivation of liberty safeguards. This last point is particularly important for midwives looking after women with learning disabilities, who need to be able to understand and apply the Mental Capacity Act, the Equality Act and the Human Rights Act to ensure that the needs of the women in their care are met and their rights upheld.

The 2022 Women’s Health Strategy sets out the Government’s ambition for England to be

“the best place in the world to give birth through personalised, individualised, and high-quality care”.

If this goal is to be achieved, training for midwives must equip them with the skills and competencies to support all women, including those with learning disabilities, through and beyond pregnancy and childbirth. In responding to this important debate, can the Minister assure the House that this training is taking place? Perhaps he could outline what steps the Government are taking to ensure that the rights of parents with learning disabilities to access maternity services free from discrimination, where their rights are respected and they receive high-quality, person-centred care, are being upheld.

Photo of Lord Allan of Hallam Lord Allan of Hallam Liberal Democrat Lords Spokesperson (Health) 1:51, 25 January 2024

My Lords, I am also grateful to the noble Baroness, Lady Taylor of Bolton, for the debate, and to all speakers, whose points will inform my contribution. Like the noble Baroness, Lady Donaghy, I was moved by the description of a new mother’s experience from the noble Lord, Lord Patel, which brought back memories of the birth of my twins across the river at St Thomas’, where the labour room has a splendid view of this building. I offer a tip to partners who are present during labour: pointing out interesting features of the Palace of Westminster and taking photos may not endear yourself to the mother, who is doing all the work. On a more serious note, it is good to be able to offer a belated and public thank you to the staff at St Thomas’, who were superb—particularly at dealing with multiple births, which I know is a much more specialist and complex procedure.

I am grateful to all noble Lords for the expertise they have shared. I will largely focus on the digital aspects, which is something that I have more hands-on experience of than medicine or giving birth. I also want to pick up the point about the workforce and the student experience. Although my children are not at the taxpayer stage, unlike those of the noble Baroness, Lady Watkins, I observe them and their peers going through the process of making their higher education choices and the kinds of calculations they make. The debt figures presented by the Royal College of Midwives that we have heard about from the noble Baroness, Lady Bennett, and others in the debate are alarming. It seems blindingly obvious that they are putting people off going into the profession, causing enormous stress for students during the process of learning and contributing to drop-out rates that are higher than any of us would like.

I hope that the Minister has something to offer in this area around how we can make sure that training to be a midwife, as well as training in other medical professions, is something that an 18 year-old, when they make those calculations, thinks is worth their while. However well-motivated they are inside, you cannot ignore the economics of being saddled with huge amounts of debt.

My first digital point is also a workforce point to a certain extent. It is about people’s changing expectations as they come into the workforce. Having survived the training and debt, as they move into work, that has to be workable for the individual based on how they live their lives today. The noble Baroness, Lady Watkins, touched earlier on scheduling and rostering, and flexibility at work. It is an issue across the wider health and care workforce, but is especially acute for roles dependent on a safety-critical presence in the workforce. These are not roles that can be moved around; people have to be present at a certain time, on a certain date and in certain numbers for safety to be maintained.

To build on the points made by the noble Baroness, Lady Watkins, this is really difficult for employers. They have to know that the right staff will be on-site to cover each shift. There is no way around that, but where this leads to inflexible rostering, that can clash with other staff needs. These may be other caring responsibilities—caring either for younger or older family members—or personal goals, such as travel, which people do have now as they enter the workforce. They may look for extended breaks—sabbaticals were mentioned—or they may want a month to go travelling. That may be a reasonable expectation people have today that they might not have had 15 or 20 years ago. Where rostering systems do not allow sufficient flexibility, staff may either leave the profession altogether, as it just does not add up, or may not accept a trust contract but move into agency work. The NHS then ends up paying more for the same person to do the job. Simply because they did not have the flexibility to take a month off, they have now moved to agency work from a full-time NHS contract. That seems to me to be an absurd outcome.

We talk a lot these days about whizzy technology, such as artificial intelligence, but what we need here are much more straightforward, efficient scheduling systems that enable staff levels to be met while giving individuals more control over the way rostering occurs. That is the expectation they have today. We need a willingness from trust management to change with the times and allow that flexibility to happen. I hope the Minister can look into the question of how we could improve staff retention through improved rostering systems—for all NHS staff, but particularly midwives in the context of today’s debate. This is basic and cheap technology that, used well, could prove to be enormously beneficial in the cost-benefit equation.

The second area I will touch on is information to mothers. This comes out as a key area of concern for respondents to the CQC maternity survey, which was referenced by the noble Baroness, Lady Cumberlege. It seems to be getting worse. In this wonderful information age, we find mothers saying that the information provision they get from maternity services is getting worse, and that seems extraordinary to me.

A key tool in improving that is offering self-help systems, where people can access information themselves. This is better for those who prefer direct access to information, but it should also lead to improvements for those who want to talk to somebody directly, because it frees up staff time to be available for those who need that direct access. Self-help access to information about your own care is critical; it can also be a benefit with language issues, as providing translation and interpretation at scale can often be done more effectively when enabled by technology than if you are reliant on getting somebody with a particular language to a particular location at a certain time.

I would also be very interested in the Minister’s thoughts on accessibility, a point rightly raised by the noble Baroness, Lady Bull. Again, if we want to make information available, it needs to be truly accessible to people, whether they have learning disabilities or any other particular requirement that means that a standard provision of language may not be as useful as something tailored to their needs.

The Government recognise this need, and they gave us a commitment. In the debate today, people have said that we need more than commitments; we need action. The commitment was very clear. The NHS Long Term Plan said: “By 2023/24”—which I think is now—

“all women will be able to access their maternity notes and information through their smart phones or other devices”.

I hope that the Minister can update us on where we are with this target, whether we are likely to reach it and what issues are surfacing. It is normal that things surface during the rollout process, but I would be interested to hear what issues are surfacing and what action the Government are taking to address those.

The third area I will address is maternity electronic health records. I have been looking at this because of an alert issued by NHS England at the end of last year about one of the systems used for managing patient records across several NHS maternity units. It was found that the system could overwrite records, which produces significant safety risks. Here is an area where I praise NHS England—as a board member, the noble Baroness, Lady Watkins, can take this back to it—as the issue was picked up, due processes were followed and an alert was issued to every trust using the system, warning them about it and making sure they put remedial measures in place. I also thank the Minister and his staff for producing a very comprehensive response to queries I made around this.

This prompted questions about the information flow in maternity care generally between GPs, hospital trusts’ general systems and these specialist maternity systems. It seems that we have ended up with a complex jigsaw of different systems handling patient records, which makes life more difficult. I would be interested in whether the Minister thinks information is flowing effectively in the context of maternity services, given that we often seem to have created dedicated systems for maternity services that may not be connected to the other systems. From the patient’s point of view, you want one integrated view of your care—before you became pregnant, during your pregnancy and postnatally—yet because we have different systems, that integration may not be taking place. That is a special challenge because the data is held by different entities. It is the classic NHS challenge that different entities have bought their own bits of this jigsaw puzzle and nobody is responsible, as far as I can understand it, for putting the pieces together.

I was also interested in this in the context of the question raised by the noble Baroness, Lady Gohir, about data collection. I suspect that some bits of this jigsaw will be collecting the data that we are looking for, but other bits may not be, yet because of the way the systems are structured, that may not be joined up, which would be a real shame. It is one thing if we have not collected the data, but it is quite something else if we have collected it but we cannot use it because it is in the wrong bit and has not been connected to the right bit.

I appreciated hearing all the experiences that noble Lords have brought to this debate and I hope my somewhat geeky contribution has flagged some issues that could contribute positively to keeping up the standards of our maternity services. If noble Lords in future find me on the Terrace staring wistfully across the river at St Thomas’, they will know that I am just having a moment.

Photo of Baroness Merron Baroness Merron Opposition Whip (Lords), Shadow Spokesperson (Health and Social Care) 2:02, 25 January 2024

My Lords, I congratulate my noble friend Lady Taylor on securing this debate and setting out the issues with her customary elegance and clarity for us to build on further. As my noble friend said, all the briefings we received in preparation for this debate referred to a very worrying situation and—I shall head this off at the pass—to the fact that Covid cannot be used as an excuse because the pressures have been building for more than 10 years, which is something that I am sure the Minister will want to address.

As we heard, despite the Government and the NHS publishing various targets, programmes, strategies and action plans over the years to improve services, and having a lot of different evidence bases to call upon, and, sadly, inquiries into circumstances where things have gone tragically wrong, it is unfortunate that we find that maternity is an example of how services have deteriorated on the Government’s watch. As my noble friend Lady Armstrong said, even with all these plans, targets and so on, without proper implementation, they do not deliver improvement.

Within all of this, we know the data is important. I noticed in his response to a Written Question from the right reverend Prelate the Bishop of St Albans last month, the Minister explained that:

“The most recently published data which measures progress against” government targets in the national maternity safety ambition

“coincided with the COVID-19 pandemic and is out of date”.

The Minister also said in his written reply that:

“The Department is working to increase the frequency and timeliness of publications”.

I am sure the whole House would agree that that would be welcome.

Does the Minister agree that it is extremely difficult to deal with any issue, including that of maternity services, without knowing the facts of the challenge? This was raised with particular regard to inequalities by my noble friend Lady Thornton and the noble Baroness, Lady Gohir.

The House will be aware of Labour’s commitment to train 10,000 more nurses and midwives every year, along with long-term workforce planning across the NHS by reviewing training and looking at creating new types of health and care professionals, drawing on a diverse skills mix. We are also committed to setting an explicit target to end the maternal mortality gap, which sees black women in the UK four times more likely to die while pregnant, giving birth or as new mothers, compared with white women. This will come partly from the aforementioned training of more midwives and health visitors but also by the incentivising of continuity of care—something referred to by the noble Baroness, Lady Cumberlege, from her experience in chairing the work that gave rise to the Better Births report. It will also come from improving course content on the presentation of illness and pain among different groups. I hope the contributions and expertise in your Lordships’ House will continue to contribute to making those commitments a reality in terms of improvement.

As we have heard a number of times in this debate, the Care Quality Commission has reported a decline in positive maternity experiences in recent years. The noble Lord, Lord Patel, described the health of maternity services as a bellwether for the health of our NHS. As we have heard, it seems that in our maternity services we are now finding that we are well behind in the maternal mortality stakes. That was not the case, but it is now. I was touched, as were other noble Lords, when the noble Lord, Lord Patel, expressed his gratitude to the thousands of mothers who allowed him to be part of their lives. I am sure that those thousands of mothers would also wish to express their gratitude to the noble Lord.

The approximately 20,000 responses to the CQC’s Maternity Survey 2022, which my noble friend Lady Donaghy referred to, showed that fewer women were being given the help they needed when they contacted a midwifery team. They were getting less help in hospital care after birth and less help with postnatal care. It also showed less confidence and trust, and a reduction in the availability of appropriate advice and support when contacting a midwife or hospital at the start of labour or while in the care of that hospital.

I thank, as have other noble Lords, the whole of the staff team who are in the provision of maternity services. As the noble Baroness, Lady Watkins, said, many of these staff go above and beyond. That is confirmed by the CQC, and rightly so. However, it is evident that there are external pressures on them that get in the way of them doing the job they need to do, and it is on this that the Government hold the levers.

The CQC has continued to raise concerns about the quality of maternity care in England over many years. In the most recent State of Care report for 2021-22, the regulator reiterates its ongoing concerns about both the safety and the ethnic inequality of maternity services, as well as the impact of poor training, poor culture and poor risk assessments on people’s care.

By September 2023, the CQC had inspected nearly three-quarters of maternity services and described the overall picture as one of a service and staff under huge pressure, warning that many patients were still not receiving safe and high-quality care. Most recently, in November 2023, around two-thirds of maternity units in England received a CQC rating of “requires improvement” or “inadequate in safety”. That compared with 55% in the previous year, so it is going in the wrong direction. I would be interested to hear the Minister’s response on this.

We have heard much in this debate, and rightly so, about maternal mortality. The latest data shows that between 2020 and 2022 it increased to levels not seen since 2003 to 2005. It is right, as noble Lords have said, that even within this extremely concerning statistic all is not uniform: the case is far worse for women who live in the most deprived areas. They are more than twice as likely to die during pregnancy, or up to one year afterwards, than women living in the least deprived areas. Between 2019 and 2021, 12% of the women who died had severe and multiple disadvantages and, as we have heard, women from black and ethnic backgrounds are three times more likely than white women to die during or up to six weeks after pregnancy, while Asian women are twice as likely.

The noble Baroness, Lady Gohir, was right to say that this broad-brush approach to definition masks the range and depth of inequalities. The noble Baroness, Lady Bull, was also right to point to the fact that inequality extends to those with a learning disability. Can the Minister say whether work is going on to produce much closer attention to the needs of groups, and to break down the nature of people within those groups, in order that we can reflect and respond to the reality of those with differing experience?

We have heard today about the tragedy of many failures within maternity services. I recall, during the many Statements that we have dealt with in this House, the expression of how devastating it is to look at these failures and to have to discuss them. Having looked recently at the independent review of maternity services at Nottingham University Hospitals NHS Trust, which is ongoing, I would say that it is staggering that it required concerned local families, MPs and others over many years to be crying out about the quality and safety of maternity services in their area. This will be the UK’s largest ever maternity services review, with around 1,700 families’ cases reportedly being examined. Donna Ockenden, who is in the lead, has said that the review will not report until September 2025 because

“no one will thank us for doing a half-baked job”.

She added that there would also be a period of family feedback, which could last until the start of 2026. This makes absolute sense, but it is worth asking why it took so long for those investigations to begin.

We have heard so much about staffing: it is absolutely key and retention is what we need. In addition, my noble friend Lady Thornton referred to the multidisciplinary training that is absolutely vital to cement the proper working practices that we need. Yet we find that so many cannot find the time to attend this training. Can the Minister say what is being done to address this?

In conclusion, the birth of a child, as we know, is a unique event. Mothers, babies and families all deserve the best. I hope that this debate and the work that may flow from it will deliver the improvements that we all need to see.

Photo of Lord Markham Lord Markham The Parliamentary Under-Secretary for Health and Social Care 2:15, 25 January 2024

I too thank the noble Baroness, Lady Taylor, for enabling us to have this debate and I am grateful for all the contributions from Members here with their vast experience and expertise. I too was moved by the words of the mother mentioned by the noble Lord, Lord Patel. The noble Baroness, Lady Merron, put it well when she spoke of the thousands of mothers who have their thanks to give to the noble Lord. I am not sure that there are many fathers who would thank to the noble Lord, Lord Allan, for his advice, but I will take it, should I be in that situation again and I may not take photos of the scenery.

I want to reassure the House that we are committed to ensuring that all maternity services provide safe and compassionate care. As many Members have mentioned, most women have a positive experience of NHS maternity and neonatal services, and outcomes have improved, with over 900 more families welcoming a healthy baby each year compared with 2010 figures. However, all women should feel confident that they and their baby will be cared for safely and, where tragedies happen, that they will be well supported and treated with compassion. We therefore acknowledge that there are unfortunately times when the care provided is not enough.

Recent independent reports by Donna Ockenden on maternity services in Shrewsbury and Telford, and by Dr Bill Kirkup on maternity and neonatal services in East Kent, and previously in Morecambe Bay, set out many examples of poor care over the years. The review into maternity care at Nottingham University Hospitals chaired by Donna Ockenden commenced in 2022, and we expect that report to be published at the end of September 2025. We take those investigations and all elements of maternity safety incredibly seriously. We understand the immeasurable impact that poor care and adverse outcomes can have on a family, and remain committed to supporting trusts to deliver safe, compassionate care and addressing the unacceptable disparities for women and babies.

While maternity services must always seek to learn and improve, I want to recognise the dedication and commitment of the vast majority of the maternity workforce. I know that everyone who joins the healthcare profession sets out to deliver safe and compassionate care, and I acknowledge the efforts and ability of the many maternity professionals who work tirelessly for the women and babies they care for.

The Secretary of State last week announced that improving care during and after pregnancy will be one of her top priorities in implementing the women’s health strategy in 2024. A key tenet of this is continuing to deliver NHS England’s three-year plan for maternity and neonatal services. The plan sets out how NHS England will make maternity and neonatal care safer, more personalised and more equitable for women, babies and families. Since 2021, we have invested an additional £165 million a year to improve maternity and neonatal care. That will increase to £186 million a year from 2024-25.

The Government have also set a national maternity safety ambition to halve by 2025 the 2010 rates of stillbirths, neonatal and maternal deaths, and brain injuries that occur during or soon after birth, alongside a further ambition to reduce the rate of pre-term births from 8% to 6% by 2025. In answer to the question from the noble Baroness, Lady Taylor, on progress to date, there has been a 23% reduction—so it is progress, but I fully admit that it is not enough.

At this stage, I want to address a lot of the points that have been made. Many noble Lords, including the noble Baronesses, Lady Taylor and Lady Warwick, talked about staffing. The noble Lord, Lord Patel, offered to come and help once more, as did the noble Baroness, Lady Watkins—I am sure she is bright enough to do it as well.

We recognise the importance of staffing. There has been a 14% increase since 2010—and, unlike other areas of the health service, the birth rate has remained stable during that time. So that is a real-time increase, for want of a better word. But I completely accept the points made about the importance of training and retention, and the point the noble Baroness, Lady Warwick, made about understanding what numbers are required to make sure we have the right provision going forward. Of course, that is what the long-term workforce plan is all about. On the retention agenda and the points made by the noble Baroness, Lady Watkins, about sabbaticals, loan repayments and smart stuff such as using technology for flexibility, and staff apps, should all be part of the toolkit. Again, I have seen some very good examples of that in places such as Milton Keynes. I am talking more generally about staff here—using a staff app to allow exactly that sort of flexibility. If we want to be a modern employer competing in a modern world, enabling sabbaticals and that sort of flexibility is, I agree, key.

Turning to the noble Baroness, Lady Taylor, and her local services, my understanding is that, hopefully, the Bronte birth unit will open again in April 2024. However, I accept that some issues have arisen there.

I say to the noble Baroness, Lady Cumberlege, that I absolutely believe in continuity of care as a key tenet in what we are trying to do. I accept that that needs to be built into the long-term workforce plan and some of those allocations. As the noble Baroness, Lady Watkins, says, it is vital that we listen not just to the mothers—that the staff are taught to listen not just to the mothers—but the partners as well.

The point made about access to interpreters is a very good one. Among the many things I shall write back on, I shall be pleased to come back on that too. An excellent point was made about ensuring that staff understand the needs of mothers with learning difficulties. That is very important, and I shall come back on the detail, particularly regarding passports.

I absolutely agree with the point the noble Baroness, Lady Donaghy, made about the long-term relationship with staff. You have to avoid a situation of winners and losers, asking, “Did we win the last battle?” All you are doing is creating bad feeling for the next battle.

I turn to the many points made regarding safety, which is key to this whole debate. The noble Baroness, Lady Armstrong, said that that time and how the birth took place defines much of a mother’s relationship with the child. As many noble Lords said, including the noble Baronesses, Lady Armstrong, Lady Gohir, Lady Bennett and Lady Thornton, the disparities experienced by ethnic minorities and those with learning difficulties are a key issue. I remember my conversation in that regard with the noble Baroness, Lady Thornton, very well.

The Maternal Health Task Force is meeting regularly; it met last September and is meeting again next week. It is chaired by Minister Caulfield and is a fundamental tool in this regard. The point made, particularly by the noble Baroness, Lady Gohir, about ensuring that we have the necessary data and analysis is vital. I shall come back to the points made about NHS Resolution. Having said all that, I would not be surprised to discover that it does not show that there are more disputes from people from ethnic minorities, because they may not feel confident enough to use NHS Resolution. There is probably quite a lot to unpack in all that, but I shall come back in writing and make sure that we also cover the point about learning difficulties.

I share the concerns raised by the noble Baronesses, Lady Merron and Lady Taylor, and others around the CQC reports. We are seeing an increase in levels of concern—50% or so—about inadequacy or need for improvement. That is clearly not a good situation.

To respond to the point from the noble Lord, Lord Patel, that it is the action that really counts, I know that the NHS has an implementation plan for each trust where there are inadequacies to make sure that they are being addressed. I have made sure to ask that I can see and understand all those and I have asked for a report in six months’ time on progress, which I am willing to share with all noble Lords here.

On the questions of whether we should be having an inquiry and further work on this and, as asked by the noble Baroness, Lady Donaghy, what would inform my view on that, I personally think that it is about whether we are really seeing progress. I am very aware, as mentioned by noble Lords, that every time you kick off a new inquiry, it can take a long time. If the action and improvement plan is put in place, I will be satisfied that we are on the right track—but, to be very open, my view will change if I do not believe that the plan is there. As we have the benefit of the noble Baroness, Lady Watkins, being an NHS board member, I say to her—I am sure it is something that is happening—that I think this would be an excellent topic for the NHS board to cover as well, because it is on the front line in all this as well.

Regarding maternal deaths, which we all agree is something of serious concern, the Secretary of State has commissioned urgent work on that. I think we all understand that it is a more complex situation; factors such as age, obesity and diabetes all make the underlying situations more complicated. I do get into the data and, just so noble Lords have all the facts, the recent increase that we saw translates to about 35 extra deaths in the period. I note—and I am just giving the data; I am not using it as an excuse at all—that Covid was responsible for 38 deaths. Covid is a big component in all this, but I do not for one moment suggest that that is the only reason. As the noble Lord, Lord Patel, said, analysing thrombosis, for example, which is a leading cause, is vital in this. The introduction of the 14 maternal medicine networks, which are specialist units set up to look at where there are complications and at likely need for things such as thrombosis, is a vital part of this. Again, seeing action on that in the report back will be key.

To respond to the noble Baroness, Lady Donaghy, I look forward to seeing the Birth Trauma Association report. Obviously, we will respond further after that.

On the points made by the noble Lord, Lord Allan, and the noble Baroness, Lady Merron, I see data as having an important role; use of the app to allow mothers to take control of their own health and data is vital. I had a meeting just yesterday to make sure that the baby red book is brought into the app as well so that, from day one, mothers can have access by proxy. I am mindful of the time, so I will cover that in detail in my letter. I will also pick up and write on the other points raised, but I again thank noble Lords. For me, the benefit of having so much experience is that we can hear these sorts of points in debates. I, for one, have found it useful, so I thank the noble Baroness and everyone else for the work they do in this space.

Photo of Baroness Taylor of Bolton Baroness Taylor of Bolton Labour 2:30, 25 January 2024

My Lords, I thank everybody who has taken part in this debate. I think we have all learned from each other, and it has been really interesting to see the different levels of experience and how they have come together, but I hope the Minister is acknowledging that, despite people coming at this from different levels of experience, the actual message is extremely clear: we have a crisis in maternity services and unless the Government take action quickly, we are going to see more of the scandals that have alarmed us so much in recent years. We all recognise the dedication of the staff and acknowledge that they do their best, but we are facing a very depressing situation and, indeed, a crisis. I know there have been calls for new inquiries and new plans, but, as my noble friend Lady Warwick said, we have many of those but we do not have the building blocks and the progress to underpin what actually needs to be done.

I am struck by the fact that we have this cycle of problems. Current midwives are overworked, so they do not have time for extra training, or to mentor students, or to listen to mothers, as several Members have said is vital. Therefore, they get burned out; therefore, we have fewer midwives and all these pressures intensify. I think that that is really the crux of where we are now. Unless we can break that cycle and find some way of giving experienced midwives the support they need, this problem is going to continue. Of course, there are problems in terms of students and drop-out rates. The noble Baroness, Lady Watkins, mentioned the cost of second qualifications, and I do not think we should ignore that as one of the reasons why so many experienced nurses are deterred from moving into midwifery. Similarly, my noble friend Lady Donaghy raised issues about pay structures. These are points that Ministers could take on board and move quickly on, and I hope that the Minister, having listened to so many voices, will feel he can have some confidence that things need to be done in certain ways.

Similarly, I welcome the evidence that the noble Baroness, Lady Gohir, gave us, which everybody took note of and understood and was a bit surprised about, in terms of the lack of data on some of the crucial issues of systemic racism that she uncovered. Maybe the answers lie, as the noble Lord, Lord Allan, suggests, in different ways of working with the IT systems, but it is something I think the Minister could make real progress on very quickly and I hope the debate has helped in this respect.

I hope that what the Minister said about the Brontë Birth Centre in Dewsbury is correct: we want to see it open in April, but it is dependent on the staff being available. Incidentally, when we lose a place such as the birth centre in Dewsbury or the facility in Huddersfield, we do not just lose the maternity and labour provisions for women, we lose the student placement positions that allow us to train more people, so it really is a very serious situation.

We can all agree that women deserve good, local facilities when they are in maternity services. All women need proper care. All midwives, I would say, deserve the joy and the pleasure of seeing women cared for properly and the healthy births that the noble Lord, Lord Patel, talked about. I think that to achieve that, we need a step change, and I hope that this debate has been one significant step forward in urging Ministers to look at this problem with a new eye and new determination. I beg to move.

Motion agreed.