Birth Trauma Inquiry Report finds a pattern of poor maternity care across the UK

The Birth Trauma Inquiry

The Birth Trauma Inquiry was the first of its kind, set up to explore what birth trauma is, what causes it, how it affects people in the UK and to identify new ways for birth trauma to be both prevented and treated. 

Across seven sessions, live evidence was heard from patients, clinicians, lawyers and other experts in maternity-related matters about the challenges facing maternity services in the UK.  

The Birth Trauma Inquiry also received written witness testimony from over 1,300 people who had lived experience of birth trauma, as well as nearly 100 submissions from maternity professionals.  

Birth trauma refers to the physical, psychological or emotional distress experienced during pregnancy, childbirth or after birth.  

Traumatic birth experiences are subjective and relate to that person’s perception of threat, and evidence suggests that as many as one in three women experience birth as traumatic. 

Birth trauma can also be used to describe the physical injuries people sustain during birth, such as third or fourth degree perineal tears, otherwise termed Obstetric Anal Sphincter Injuries (OASI).

Lily had the privilege of attending all but one of the live evidence sessions and producing contemporaneous transcripts to assist with the preparation of the evidence and the Inquiry report.

Impact of birth trauma 

The effects can be devastating and life-altering, including profound psychological, physical and economic impacts which affect all aspects of a woman’s life, from her relationship with her baby, her family and friends and her ability to work. In cases where a child has a severe disability, siblings live with the knowledge that when their parents die they may take over the care of the child, which is a huge responsibility to live with.

A failure to listen  

The Birth Trauma Inquiry report highlights a failure from maternity care professionals to listen to women. Parents’ concerns that something was wrong were often dismissed or ignored and women reported being told by healthcare professionals that they were being over-anxious. Partners also described how they were ignored by staff and left unaware of what was happening.  

When things did go wrong, the inquiry heard stories from women whose complaints were treated dismissively, whose birth notes were falsified or lost and whose experiences with failings in care went unacknowledged. The inquiry also heard how attempts by parents, who had experienced a difficult birth where mistakes were made, to later obtain answers about why things had gone so wrong resulted in efforts to cover up or minimise the harm caused.  

Hearing women’s experiences of maternity care, where reasonable care was not provided, and where their concerns were ignored or dismissed are unfortunately all too common themes in medical negligence cases. It is encouraging that the scope of the inquiry sought to understand why injured people take legal action.  

In fact, the Birth Trauma Inquiry Report, published on 13 May 2024, found that in many of the cases they heard, “the trauma was caused by mistakes and failures made before and during labour”. The inquiry reported that “frequently, these errors were covered up by hospitals who frustrated parents’ efforts to find answers”.  

A lack of informed consent 

Poor consenting processes were highlighted multiple times by experts on the panels at the inquiry’s oral evidence sessions. Women with lived experience of birth trauma told the inquiry that they were not informed antenatally of their increased risks of particular complications, such as perineal tears. A sentiment echoed by panellists was that there is a paternalistic attitude towards women and a concern not to frighten them.  

The Inquiry’s report found that the problems with consent start antenatally and that although the case of Montgomery v Lanarkshire established that patients should be informed about risks, this is often not happening in practice. One of the report’s 12 recommendations to the UK Government relates to the need to respect mothers’ choices about giving birth.

Conclusion  

The Birth Trauma Inquiry uncovered a “pattern of poor maternity care across the country” where there is a postcode lottery in care and where poor care is too frequently tolerated as normal.  

Other key themes that emerged during the inquiry’s investigations included poor communication, with parents not being kept informed of what was happening, a lack of pain relief being given to women during labour, a lack of kindness and compassionate care from health professionals, the impact of breastfeeding problems in contributing to birth trauma and poor post natal care, which the inquiry noted was mentioned in nearly all the submissions they received.  

The inquiry’s report set out a vision for good maternity care and made 12 core recommendations to the UK Government, to improve the safety of maternity care for all women and to work towards a maternity system where “poor care is the exception rather than the rule”.  

Following the launch of Birth Trauma Inquiry’s report, others have been encouraged to share their stories and experiences.  It has sparked an important national discussion on the need to improve the quality and consistency of maternity care in the UK. With hope, the continued awareness and pressure for reform, will lead to improvements in the maternity system that reduce the incidence of harm and trauma on so many families.