Since 2017, Donna Ockenden has spent much of her time gathering testimony about the very worst things that can happen during childbirth: death or serious injury for mothers and babies. The senior midwife did this first as chair of the independent review into failings at the Shrewsbury and Telford Hospital NHS Trust, which concluded in 2022 with the horrifying finding that women had been blamed “for their poor outcomes, in some cases even for their own death”. She is now doing so again, this time as chair of a review into the Nottingham University Hospitals NHS Trust. It can be harrowing work.
“Family voices are and always should be at the heart of any inquiry or review,” Ockenden, 58, tells me when we speak on a video call. Impeccably turned out, with short blonde hair, red lipstick and a string of pearls, she has a direct, no-nonsense manner. “There have been times when I’ve met with a family whose baby has died avoidably, or I’ve met a family where the mother has died, and at the end of the day all I can do is sit in my hotel room and cry.”
Ockenden is no stranger to adversity. “We grew up in complete poverty,” she says of her early years in Wales. At 18, she found herself homeless and solely responsible for her four younger siblings. These experiences have given her a strong sense of justice, and of the importance of listening to people. Her formative professional experiences cemented this. As a newly qualified midwife in the 1980s, Ockenden looked after a newborn called Gina who had been transferred from another hospital in a very poor condition. These ended up being the final six hours of Gina’s life.
“I made a promise to her, that however long or short my career was in maternity services, I would do all I could do make care safer,” says Ockenden.
Today, improving the UK’s maternity services by exposing the extent of its problems has become her driving purpose. “Having met with thousands of families,” she says, “I’ve realised that maternity and perinatal services in a typical trust often don’t understand or appreciate the long length of trauma associated with maternity harm.”
The Nottingham review was set up just a few weeks after Ockenden published her report on Shrewsbury and Telford, and was initiated at the request of families after dozens of babies died or suffered serious injuries between 2012 and 2020. The scope of the work quickly expanded, and Ockenden is now reviewing the cases of more than 2,000 families who have experienced stillbirth, neonatal death or maternal death, and of babies diagnosed with brain damage, as well as examining antenatal care. It looks set to become the largest-ever review of a single NHS service. Many of the cases are horrendous. Jack and Sarah Hawkins, whose daughter was stillborn in 2016, recently discovered that the hospital allowed her body to decompose so badly after her death that she had to be “triple-bagged” before burial.
Clearly, the failings were catastrophic and broad-ranging. But as interviews with families and staff members got underway, Ockenden noticed one issue coming up again and again: racism.
South Asian women told Ockenden that midwives and nurses had imitated their accents
“There were literally countless families saying they felt they were treated worse than their white counterparts, and non-white junior doctors raised it too, telling me: ‘Donna, everything the women say affects us too.’”
The incidents women reported to Ockenden were broadly split into two categories. The first is structural discrimination in how services are set up. Frequently, women who do not speak English said that interpreters were not available while they were in labour, making it difficult for them to understand what was going on and to give informed consent. One woman who needed an emergency C-section had to call her mother in Pakistan from the delivery suite to translate. Videos explaining safe sleeping and other aspects of infant care were available only in English. A number of Muslim women complained that they were dismissed when they raised concerns about being assigned a male sonographer.
The second category of incident was more explicit racism. A number of south Asian women told Ockenden that midwives and nurses had imitated their accents and body language, and that colleagues sometimes laughed along. Roma women reported being shouted at and looked at disparagingly because of their clothing. In one instance, a Roma woman said a sheet was thrown at her when she asked for her blood-stained bedding to be changed. It seems unsurprising that Ockenden reported in 2023 that ethnic minority families had a “deepened mistrust” of the service.
Racism is not the primary focus of the inquiry—which is set to conclude later this year—and indeed there are plenty of cases of serious failings in which racism played no part, but Ockenden felt compelled to act. Since early 2024, she has sent a number of letters to the Nottingham trust outlining her concerns around racism and discrimination. The chief executive, Anthony May, responded that Ockenden’s findings make for “difficult reading” and pledged to “address these issues as quickly as we can”, with a programme of training on cultural competency, improvements to interpreting services, and efforts to increase diversity in the maternity workforce.
“To be fair to the trust, they’ve taken a lot of what I said on board,” Ockenden tells me. But despite some improvements, the issues remain; as she continues interviewing families and staff, Ockenden still hears stories of racism and discrimination. “This is happening in the here and now, not in the past,” she says.
The persistent problems Ockenden has highlighted in Nottingham point to a much wider problem in our maternity services. We have known for decades that black and Asian women are more likely to die in childbirth or suffer serious complications than their white counterparts.
The most recent data, published in January 2024, found that, compared with white women, black women were 2.8 times more likely to die during or up to six weeks after pregnancy, while Asian women were 1.7 times more likely to die. South Asian women are more likely to have perineal tears and major obstetric haemorrhage; black women are significantly more likely to experience pre-eclampsia. Both groups face a heightened risk of stillbirth. Studies have found that non-white women are less likely to be offered pain relief or listened to when they report problems or ask for help.
It has been the case for years that racial disparity is particularly stark when it comes to maternity outcomes. This trend is reflected in healthcare more widely: a 2021 report for the NHS Race and Health Observatory concluded that people from ethnic minorities “experience inequalities in health outcomes as well as inequalities in access to and experience of health services” across the board. The pandemic exposed these racial inequalities, with ethnic minority groups experiencing significantly higher rates of Covid infection and death. And yet these problems persist.
“We’ve got a significant amount of data. We’ve got the voices of women and birthing people from a range of reports,” says Janaki Mahadevan, one of the CEOs of Birthrights, an organisation that campaigns on maternity policy from a human rights perspective. “But what… practical steps are being taken to start moving towards solutions? That’s where we’re stumbling.”
In recent years, women of all demographics have reported often serious issues in the quality of the maternity care they receive. In May 2024, the UK parliament’s Birth Trauma Inquiry concluded that poor care is “all-too-frequently tolerated as normal”. It heard testimony from 1,300 women, many of whom complained that they were ignored when they raised concerns, left without pain relief, mocked or yelled at. In keeping with past studies and reviews, the inquiry found that women from ethnic minority groups experienced especially poor care. The inquiry called for a recruitment drive for midwives, anaesthetists and obstetricians to ensure safe staffing levels, as well as efforts to respect women’s choices and tackle inequalities.
Last September, the Care Quality Commission reported that almost half of the maternity units it inspected were rated either as “requires improvement” or “inadequate”. This is a bleak picture, but hardly surprising. In common with the rest of the NHS, maternity services face resourcing and staffing issues, following years of austerity and the increased pressure of the pandemic. In 2022, the government announced a funding increase of £127m for NHS England maternity services, but this fell short: a year earlier, a parliamentary committee had determined that an annual increase of between £200m and £350m was required to address gaps and failings.
Amid this mounting evidence that England’s maternity services are in serious crisis, women from marginalised groups consistently report worse experiences and have statistically poorer outcomes. Clearly, resourcing plays a part. If maternity units are struggling to attract enough midwives, nurses and doctors, it follows that they will also struggle to have a well-staffed and efficient interpreting service, for instance. In 2021, the NHS launched “Core20PLUS5”, a plan to reduce health inequalities across the board, not just in maternity services. One of its aims was to ensure continuity of care for pregnant women from black, Asian and other ethnic minority communities and deprived groups. Continuity of care is the principle that women should be seen by the same midwife, or team of midwives, for the duration of their pregnancy. This builds trust in the healthcare system, produces a higher quality of care, and has been found to lead to better outcomes for pregnant people, mothers and babies.
I’ve witnessed first-hand the impact of continuity of care. During my first pregnancy in 2021, I saw a different midwife at every appointment. They had no idea who I was, and each time asked for basic information such as my name and ethnicity. This led to errors. One midwife mistakenly wrote that I was east Asian rather than south Asian, which meant a planned test for gestational diabetes was cancelled. (People of south Asian descent have an increased risk of developing this condition; when I realised the error, I flagged it and had the test.)
In one particularly abysmal appointment late in the pregnancy, a midwife berated me for asking questions about pain relief options in birth and the process for requesting an elective C-section. She told me: “You haven’t bothered to do your own research and there’s a room full of women out there waiting to be seen,” ignoring the fact that I was also a woman who had waited—for more than an hour—to be seen. When I became tearful, she told me to calm down lest I harm the baby, and suggested I seek mental health support. I don’t know if this poor treatment had anything to do with my ethnic background—I suspect not—but I later made a formal complaint. The hospital apologised and provided me with continuity of care for the remaining month of the pregnancy, which meant being assigned a specific midwife. She knew my name and had read my notes, and I had her mobile number to call in an emergency; the experience couldn’t have been more of a contrast to the preceding eight months.
When the Core20PLUS5 plan was launched, the goal was for 75 per cent of women from ethnic minorities and the most deprived areas in England to receive continuity of care by 2024. However, the actual rate of women receiving this type of care has never been close to the target. In September 2022, NHS England scrapped the target date all together. “For this model of care to be implemented safely, it requires adequate staffing levels,” says Tracey Bignall, director of policy and engagement at the Race Equality Foundation.
The Royal College of Midwives has been warning of a maternity staffing crisis for several years now. When they surveyed midwives in 2021, more than 57 per cent said they planned to quit, citing concerns about staffing levels and fears over patient safety. As I experienced, the impact of this goes far beyond an inability to deliver against targets; it affects the very nature of care provided. A generous explanation is that if staff are burned out and demoralised, they are unable to provide adequate care.
“Staff are overstretched and under high amounts of pressure,” Ockenden tells me. “You hear of midwives not being able to attend to their basic sanitary needs when they’ve got their periods because they cannot get to the loo. They’re often left running on empty. However, sometimes there is a lack of civility and compassion that is in no way acceptable—the way staff speak to mothers and families, the lack of listening and the lack of respect.”
Reflecting dynamics in wider society, studies consistently show that this problem is even more acute when it comes to the treatment of ethnic minority women. “This isn’t about trying to place blame on individual midwives, since the profession is incredibly under strain,” says Mahadevan. “It’s actually the system that is the issue here. It’s not serving anyone—neither the people delivering the care, nor the people who should be at the centre of that care.”
In May 2022, Birthrights published “Systemic racism, not broken bodies”, a report on a year-long inquiry they led into racial injustice in maternity services. Overseen by an expert panel of obstetricians, midwives and other experts, the inquiry heard evidence from more than 300 people with the aim of exploring the cause of inequalities in maternity outcomes and experiences. The title of the report was deliberately provocative, taking aim at the idea that women from ethnic minorities have “broken bodies”, or experience worse outcomes because they might be more likely to be economically deprived or have co-morbidities.
“There’s a stark lack of acknowledgement of the primary drivers that lead to disproportionate poorer outcomes,” says Mahadevan. “At the very root of it all is a reluctance to call out structural racism.”
The Birthrights inquiry found that black and brown women were often ignored or disbelieved, were not given the means to give informed consent (typically due to inadequate interpreting services) and were subject to racism by caregivers. It also highlighted outdated medical training. The Apgar score, for instance—a system to evaluate the health of newborns—was developed based on white European babies, with some guidance saying that a baby’s skin should be “pink all over”. Clearly, this doesn’t apply to babies who do not have white skin.
“An indicator of anaemia is said to be pale skin. But how is this shown in black skin?” says Bignall, who was on the expert panel for the inquiry. “Staff must be trained to recognise how medical conditions present on different skin tones.” Similar problems were highlighted in the diagnosis of sepsis in mothers and jaundice in babies.
The racial disparity has reduced, not because fewer black women are dying, but because more white women are
Bignall highlights various recommendations: retraining for maternity staff to address systemic biases and improve care; better use and collection of ethnicity data; targeted interventions for high-risk groups, to address issues such as higher rates of stillbirth among black and Asian women; investing time and money in tackling racism; and establishing and empowering working groups. Birthrights is calling for a new maternity act to enshrine some of this in law; calling for rights, respect and equality for all birthing people, including those from racial minorities. “We’re calling it a Safe Maternity Care Act that ensures safety, accountability, freedom of choice and equality are at the core of the maternity system,” says Mahadevan.
More insidious, and less easy to fix, is the problem of the attitudes and behaviours that lead to staff mocking women’s accents, or disbelieving a mother who says she is in pain. And in a context of general crisis in maternity care, even the seemingly straightforward problems—outdated training, a shortage of interpreters—are not so easy to deal with. One particularly sharp distillation of this is the fact that the racial disparity in maternal mortality has reduced slightly in recent years, not because fewer black women are dying in childbirth, but because more white women are. The UK still has very low maternal mortality rates by global standards (13.41 deaths per 100,000 women) but, nonetheless, this is a deeply worrying trend.
The last few years have seen almost unprecedented scrutiny on the UK’s maternity services, from Ockenden’s two reviews to the parliamentary Birth Trauma Inquiry, and people working in the sector say there is concern about improving standards and addressing persistent racial disparities. But from the outside it can seem that there is stasis, or that if there is a push for action, it doesn’t amount for much. In 2022, for example, Boris Johnson’s government set up the Maternity Disparities Taskforce to address unequal outcomes. It was supposed to meet and report every two months, but in 2023 it met only twice.
From the outside looking in, it is hard to escape the sense that the crisis in maternity care is being treated as an afterthought, as women’s healthcare so often is. This is profoundly unsettling, given that pregnancy and childbirth affect all of us, not just the people physically carrying and birthing the baby.
For her part, Ockenden continues to gather evidence on hospital failings in Nottingham. The review is set to conclude this year, and a report is not due until 2026. In the meantime, Ockenden has no time for defeatism. She bemoans–with characteristic energy—some of the attitudes she sees around improving interpreting services. “People say, ‘We can manage it in clinic but we’ll never get it right on the labour ward’, but that’s not good enough. We need to come up with a solution.”
She pauses for a moment before adding: “We’re all touched by maternity services. Everyone has to be born.”
