Delivering the Truth: Why NHS Maternity Care Is Broken and How We Can Fix It

For any woman planning a pregnancy in the UK, concerns about the safety and quality of NHS maternity care are increasingly valid. Numerous inquiries have highlighted avoidable deaths of mothers and babies, prompting a national review to address systemic issues. However, Dr. Lorin Lakasing, a London-based obstetrician and fetal medicine consultant, expresses skepticism that the latest investigation will yield significant improvements.

A Decade of Deterioration

Dr. Lakasing points to a troubling trend: despite repeated inquiries and reforms, maternal care is not improving. In fact, the maternal death rate has risen by 20% over the past decade. Her insights stem from over 30 years of clinical experience delivering babies, coupled with her role as an expert witness in medical malpractice court cases. She recently published Delivering the Truth: Why NHS maternity care is broken and how we can fix it together, outlining her proposals for safer childbirth within the NHS.

Five Key Problems Plaguing NHS Maternity Care

1. The Push for ‘Normal’ Births

Maternity care, according to Dr. Lakasing, uniquely prioritizes the avoidance of medical interventions, sometimes to a detrimental extent. The emphasis on “normal” or “natural” births – vaginal deliveries without medical assistance – has, in some cases, led to women being denied Cesarean sections despite requesting them.

While C-sections carry their own risks, including longer recovery times and potential complications in future pregnancies, Dr. Lakasing explains that a previous target of keeping C-section rates below 20% fostered unsafe practices. “Chasing this target promoted some of the worst practices seen on labour wards,” she states, citing futile inductions, delayed responses to fetal heart rate concerns, and damaging attempts at vaginal delivery.

The 20% rule was abandoned in 2022, with NHS England now advising hospitals not to discourage women from choosing C-sections, and official guidelines recognizing a woman’s right to choose the procedure even without medical necessity. The Royal College of Midwives (RCM) also apologized in 2022 for its role in promoting “normal” births that contributed to maternal and infant deaths, acknowledging an overemphasis on a particular ideology. However, Dr. Lakasing notes that some universities continue to teach student midwives that minimal intervention is the best approach to childbirth.

2. The False Dichotomy of ‘Low-Risk’ and ‘High-Risk’

Dr. Lakasing criticizes the practice of categorizing all women into “low-risk” and “high-risk” groups. “The notion that you can have a binary classification of risk is ludicrous,” she argues. This categorization can create a false sense of security, leading to inadequate attention when complications arise in women deemed “low-risk.”

High-risk pregnancies are typically overseen by obstetricians, while low-risk pregnancies are primarily managed by midwives, who outnumber doctors in the NHS by approximately five to one. Dr. Lakasing believes this division can delay necessary intervention. “Where you notice trauma is women categorised as low risk who then develop a problem that doesn’t get the attention it needs,” she explains. She supports the idea of joint care by midwives and doctors for all women. A recent inquiry into the Shrewsbury and Telford Hospital recommended that a woman’s risk status be reassessed at every antenatal check.

3. The ‘Deskilling’ of Midwives and Obstetricians

Dr. Lakasing expresses concern about declining training standards for both midwives and obstetricians. Midwives are no longer required to complete general nursing training before specializing, which she believes diminishes their ability to recognize and respond to broader medical issues during pregnancy and postpartum. “Common causes of death relate to sepsis or high blood pressure. They’re not classic obstetric causes,” she explains. “People are slow to pick up on sepsis in a way that someone who has had general nursing training would not be.”

Obstetricians also receive less hands-on training due to the implementation of the European Working Time Directive, which limits working hours. While intended to improve doctor well-being, Dr. Lakasing argues it has reduced practical experience. She advocates for a “bold revision of the midwifery and obstetric training programmes.”

4. Staffing Shortages and Workload Imbalance

Insufficient staffing levels are a recurring problem during childbirth, according to Dr. Lakasing. “One of the problems is getting enough hands to do what needs to be done,” she states. The ideal ratio is one midwife to one woman in labor, but this is not always achievable due to unpredictable workloads.

While overall midwife numbers appear high, Dr. Lakasing points out that many have transitioned to management roles, reducing the number of midwives providing direct patient care. She calls for more accurate tracking of frontline midwife numbers and criticizes the addition of management layers that don’t directly improve patient care.

5. Top-Heavy Management Structures

The NHS’s complex management structure not only diverts staff from patient care but also hinders the work of those who remain. Dr. Lakasing recounts an instance during the COVID-19 pandemic where only two midwives and one student were available on a labor ward, leaving numerous women unattended. Despite the crisis, the lead midwife was reprimanded for missing a meeting about recent pandemic procedures, highlighting a disconnect between administrative priorities and frontline needs. Eight qualified midwives were present at the meeting but did not offer assistance on the labor ward.

Dr. Lorin Lakasing is a Consultant obstetrician and gynaecologist at Imperial College Healthcare NHS Trust and has been a NHS Consultant in Obstetrics and Fetal Medicine since 2004 (Lorin Lakasing).