The Maternity and Newborn Safety Investigations programme (MNSI) welcomes today’s publication and recommendations that call for safe staffing levels, mandatory training on trauma-informed care and universal access to specialist maternal mental health services.

The report from the All-Party Parliamentary Group on Birth Trauma reviewed more than 1,300 submissions from people who had experienced traumatic birth, as well as nearly 100 submissions from maternity professionals. It also held seven evidence sessions, in which it heard testimony from both parents and experts, including maternity professionals and academics. MNSI submitted written evidence and are pleased to see many of our findings echoed in the report.

Sandy Lewis, MNSI Director said:

“Sharing experiences and learning from maternity care is an important mechanism to ensure improvements are made and MNSI welcomes today’s report and recommendations. Sadly, there were a huge number of experiences of traumatic birth shared with the inquiry. We acknowledge the significance of trauma and injury, as we see the impact frequently in our own investigations. This is an area which is often not discussed within current or subsequent pregnancies and impacts on women and their families experience.

We are pleased to see the recommendation calling for universal access to specialist maternal mental health services across the UK. MNSI investigations have found that these services aren’t always readily available or accessible to all. In 2022, we reviewed a small number of maternal collapses at one trust; these highlighted some concerning areas of the care women receive. All the women we reviewed experienced life changing physical and psychological injuries. These included permanent disability and the diagnosis of post-traumatic stress disorder (PTSD). We found that the follow up was limited or not undertaken at all, the communication from the trust was inconsistent and signposting to other services did not occur.

I want to thank the mothers and families that came forward to share their experiences. I have no doubt this will have been profoundly difficult. Their openness and commitment to support improvements in this area of care is both brave and humbling.

The report echoes themes of MNSI’s national learning report published just last week. We know that increased work demands and reduced capacity to respond are leading to poor outcomes for mothers and babies. This finding is not new, and we hear frequently that staffing shortages have a significant impact on safety and quality of care.”

We look forward to collaborating across the sector to take forward the recommendations made today. MNSI has a unique insight into many cases of birth trauma and we hold a responsibility to those families we work with to share learning that supports service improvements.

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