When working on the programme for the National Maternity Safety Conference, Baby Lifeline’s aim was to bring together parent campaigners, experts and frontline professionals for a day of learning together for a safer maternity future.
The day was based around vital elements of improving safety in healthcare: listening to families, learning from the past, learning from best practice, achieving equity, and the workforce.
Now we’ve had time to reflect on the sessions at the conference, there was one key theme that ran throughout the whole event that particularly resonated with us, and that was the importance of listening – to families and to one other – to create a safer and better culture in maternity services.
Here are some of the key points we heard, which will inform our thinking from now on:
1. “Denial is the thief of all learning
It was Derek Richford, grandfather of Harry Richford – who died at just seven days old following failings at the East Kent Hospitals Trust – who first said the phrase that would come to define the whole event: “Denial is the thief of all learning.”
During the morning’s Family Voices session, Derek and fellow speakers and parent campaigners, Kayleigh Griffiths, and Jack and Sarah Hawkins, relayed the battles they went through trying to get their respective NHS Trusts to listen to them following the preventable deaths of their children and grandchildren.
Kayleigh recalled how, following the death of her baby girl, Pippa, at one day old, she “called time and time again”, but her “concerns weren’t heard…”.
Sarah Hawkins went on to say that, following the tragic death of her baby daughter, Harriet, she and her husband Jack, dealt with denial on an organisation-wide scale:
“The cover-up has been just as bad as our daughter’s death, I can honestly say that,” she explained.
Despite the tragedy and trauma these families have gone through, they spoke at our conference because they want Trusts to engage with those who have experienced avoidable harm, and the learn from mistakes.
“Involve families, believe them,” summed up Sarah. “We’re an opportunity to learn from, we’re not a threat.”
During her session, Baby Lifeline Honorary President Donna Ockenden also reflected on her own work in investigating avoidable harm, and the opportunity that listening to families gives:
“If you stop listening to families, you lose so much,” she stated. “One of the key roles of midwives and clinical directors is to listen to families.”
2. “Numbers obscure the human experience”
It was Professor Jacqueline Dunkley-Bent, Chief Midwifery Officer for England, who said “numbers obscure the human experience”, during our session entitled, ‘Safer systems: Learning from best practice’.
Nafiza Anwar, Director and Co-Founder of the Association of South Asian Midwives, echoed the need for personalisation in the following session covering achieving equity. “Approaching every mother and birthing person as the individuals they are, will lead to safer maternity services…Personalised care is key to ensuring the best possible outcomes,” she stated.
Dr Andrew Cairns, Consultant Perinatal Psychiatrist, MBRRACE-UK Maternal Mortality and Morbidity Confidential Enquiry Assessor, added: “We need to understand women and their stories and be compassionate around that, in order to provide the best care.”
An MBRRACE-UK report entitled ‘Saving Lives, Improving Mothers’ Care’, published in November 2021, found that maternal mortality rates for Black women are four times higher than for White women. They’re two times higher for mixed ethnicity women and almost twice as high for Asian women.
“Racism in maternity care is an urgent human rights emergency,” stated Sandra Igwe, Founder of The Motherhood Group, and Co-Chair of the National Inquiry into Racial injustice in Maternity Care, and author of ‘My Black Motherhood: Mental Health, Stigma, Racism and the System’.
Not listening to women, denying them adequate pain relief, and misunderstanding them when they are trying to advocate for themselves, are just some of the micro-aggressions individuals experience during childbirth, explained Nafiza.
“It’s about being heard, being seen, and being respected,” she said.
3. “Listening is often more difficult than ‘command and control’”
Professor Michael West, Visiting Fellow, The King’s Fund, Professor of Organizational Psychology, Lancaster University, and Emeritus Professor, Aston University, delivered one of the afternoon’s keynotes, focussing on ‘Promoting a compassionate culture’.
Compassion towards patients in pain or distress involves attending to them, understanding them, empathising with them, and helping them, he explained.
Amongst health care professionals, providing this kind of clinical compassion is associated with “lower levels of depression, anxiety and distress”. And studies have shown that it doesn’t affect the length of encounters between them and their patients, he added.
Leaders have an important role to play in instilling this healthier, safer way of working within maternity services, Professor West argued.
“What they model in their own behaviour tells us what they value,” he explained. “Leaders who listen, have dialogue, and help those they lead by ensuring they have the appropriate resource to do their jobs effectively.”
Compassionate leadership should not be dismissed as soft and fluffy, our keynote speaker cautioned: “This is not an easier way to lead. It takes huge courage to lead compassionately.”
“The compassion we show to each other is the compassion we show to mothers, birthing people, families, and communities,” he said. “Compassion is also about having the courage to challenge corrosive cultures in our workplaces.”
During his closing keynote speech, Eddie Morris, President of the Royal College of Obstetricians and Gynaecologists, and Chair of Baby Lifeline’s Multi-Professional Advisory Panel, added: “If you [as a healthcare professional] are not being listened to, tell someone.”
4. “We must listen to staff on the ground. They want their voices to be heard”
“Trusts all over the country have been working really hard. We are seeing midwives and doctors coming together to improve care. But workforce planning and staffing are the number one priorities,” said Donna Ockenden during her opening session at #MatSafety2022.
This involves focussing on retention as well as recruitment. “We must listen to staff on the ground. They want their voices to be heard. They want to stay in the NHS, but we’ve got a lot of work to do to ensure this happens,” she stated.
This listening is likely to involve finding out how to reduce the pressure experienced by individual midwives and other clinical team members.
“We are seeing a continuing and deeply worrying rise in staff stress,” explained Professor West, later in the conference. “There are serious consequences for those suffering from stress and burnout. This has an impact on patient care… A consequence is that staff are leaving the NHS.”
5. The take-away message was, “Go home, think and question”
Of course, we can listen all day long, but effecting change is different.
The most satisfying part #MatSafety2022 for us at Baby Lifeline was the feedback we received from delegates in the days after the conference. This included a tweet from Consultant Midwife Sarah-Jane Pedler, in which she said that, for her, “the take home message” from the event was “to go home, think and question”.
Meanwhile, Lindsey Burningham, Lead Midwife for Governance, Quality Improvement & Transformation at Dorset County Hospital, also took to Twitter to tell us that she’d had a “fantastic inaugural meeting of the newly restructured Maternity Safety Team @DCHFT,” and how she’d used what she’d learned at #MatSafety2022 to set the team’s objectives and define its vision.
Lindsey shared how she began the day by acting on what she’d heard, ensuring everybody in the team was listened to. “[We] started with a round robin to facilitate everyone’s voice – brilliant,” she wrote.
Thank you, Lindsey, everyone here and Baby Lifeline completely agrees.
We’re already listening out for ways to build on the success of this year’s conference, so please do get in touch and let us know your thoughts.
All the sessions from #MatSafety2022 are now available online.
