Ockenden Report – MASIC Statement

We would like to thank Donna Ockenden and her team for their comprehensive pursuit of the facts, and for helping bring to light the shocking events that have occurred in maternity services provided by The Shrewsbury and Telford Hospital NHS Trust.

As a charity we know that the now abandoned ‘Campaign for Normal Births’, the reported cases of inappropriate use of instruments to assist vaginal birth and not performing caesarean sections when needed, has led to too many women needlessly suffering life-changing injuries. We note the committee recognised that maternity units appear to have been penalised for high caesarean section rates and recommended that there should be an end to the use of total caesarean section percentages as a metric for maternity services.

We know that for every woman who presents with these injuries there are countless more suffering in silence. So it was with shock, anger and sadness that we read the report and read the countless examples of women who have endured the most shocking experiences, that time and time again women’s concerns were not listened to.

Descriptions of physical and psychological trauma, pain, lack of attention, vulnerability, unkind words, swearing, sarcasm and bullying towards women, as well as unkind treatment of colleagues amongst midwives and obstetricians were widespread throughout the review.

The review team heard recollections from women relating to feelings of loss of control and power (2016), excessive and painful vaginal examinations (2003) and not being listened to (2002; 2004; 2015; and 2016). This resulted in significant psychological trauma for women and their birth partners.

Here at MASIC we are voice for all women who have suffered birth injuries. No woman should go through these horrific experiences because of systematic failures of care. As the Health Secretary Sajid Javid said yesterday: The only normal birth is a safe birth for mother and baby.

We know that the cases of maternal injury highlighted in this report will be the tip of the iceberg in terms of the number of women who have sustained birth injuries across the UK, many of whom are still enduring the mental and physical impacts of suffering such injuries. Sadly, when women whose stories were included in the report did ask for help, they were frequently ignored or falsely reassured that their injuries were normal.

We welcome the report’s local and national actions for NHS Maternity Services in England and the learning which must now take place. NHS maternity services must not, and cannot, focus on the implementation of midwifery continuity of carer. We endorse ‘Improving postnatal care for the unwell mother’ – crucial in identifying and supporting women with birth injuries, and ‘Meaningful incident investigations with family and staff engagement’ – crucial to ensure women’s and families’ voices are heard and they do not feel shamed, intimidated, and belittled when they do speak out.

Given the findings in the report, and the many examples listed, we also feel it’s now the time to have a wider discussion around instrumental births – particularly the use of forceps and informed consent. We cannot continue to stand by whilst women are injured, when there are steps that can be taken to reduce these injuries and the lifelong implications these have. This report must now be the catalyst. Personalisation of choice and care should be at the centre of nationwide maternity care.

Thanks to the bravery and determination of all the families in sharing their experiences. Never again should families be left to grieve or suffer in isolation, with the additional pain of feeling their legitimate concerns are being ignored.