National review of maternity services in England 2022 to 2024

Effective communication is vital to ensure women are supported to make informed decisions and feel listened to if they raise concerns.

NICE guidance states that services should use clear language, provide timely information and offer regular opportunities for questions. It also highlights the importance of considering people’s individual needs and preferences.

In our 2022/23 State of Care report, we identified poor communication as an emerging theme from our initial inspections. Now that the programme has finished, we remain concerned that communication is not always good enough, particularly for those with protected characteristics under the Equality Act. Communication is also often the subject of formal complaints received by services, who have a responsibility to ensure all women are given the information they need, in a way they understand it, to make informed decisions and consent to treatment.

Communication challenges

In the feedback we received on inspections and through our Give feedback on care service, negative comments about communication during the maternity pathway outweighed positive comments. Many people told us that a lack of information negatively affected their maternity experiences and sometimes resulted in different birth outcomes than they had envisaged or hoped for:

Communication should just be better, it would help if the staff remembered that it might be all routine for them, but for patients it's very much a new and potentially traumatic time. And communicating in a sensitive way goes a long way.

Nothing was explained to us at all. Everyone we spoke to had traumatic births during this period. We had been warned that they leave you and ignore you completely, which they did. You have to shout to have someone come and look at you, and fight to be heard.

Many people highlighted poor communication during the antenatal pathway, noting they were not given enough time to ask questions. We also heard that staff did not always provide enough information about the harms and risks associated with their pregnancy. Some of these people told us about how they were made to feel like an inconvenience:

They honestly made me feel like I was inconveniencing them and they were rushing through patients. They didn't take time to ask if I was OK and explain what ANYTHING meant. One even scared the life out of me by misdiagnosing me, luckily me and my midwife caught the discrepancy and queried it. I feel they speak to me as if I'm incompetent and unable to comprehend and then tell me to forget it and not worry when I ask genuine questions/worries.

In addition, several people told us they felt “fobbed off” and lost trust in the people caring for them:

Some of the midwives don't listen to your concerns and you feel like you’re always being fobbed off or your concerns aren't being listened to…

I asked several times to be examined, to which I was told there was no need! I couldn't even sit down my baby had dropped so low, at 7ish I had a bad bleed so someone finally come and examined me and was told I was 7cm!! I had been saying for hours I was progressing and was fobbed off.

This feedback is supported by the findings of our 2023 Maternity survey, which found a 5-year downward trend for respondents saying they were ‘always’ given the information and explanations they needed while in hospital after the birth. This year’s results found 60% of respondents reporting that they ‘always’ received the information and explanations they needed, compared with 65% in 2018.

Communication around induction of labour was a key issue. Inductions are often offered when babies are overdue or if there is a risk to their health. While inductions are becoming more common, it is vital that staff recognise that the process can be difficult for women as some may be disappointed about being induced and the process can be painful. Effective communication therefore plays a key role in shaping the experience.

Inductions are often planned in advance and while it may be medically appropriate for someone to wait to be induced, we found that this is not always explained to women. Some women felt they were given insufficient information to understand the reason for delaying an induction, which increased their anxiety about the consequences for their health and their baby.

On a broader level, a lack of mental health support during the maternity pathway emerged as a theme from our analysis of experiences received through Give feedback on care. Despite a recent focus on perinatal mental health, including in the NHS Long Term Plan, many women felt better communication could have reduced their anxiety. People explained that pregnancy and birth is an overwhelming experience and without clear communication, levels of anxiety can increase. Again, it is important that staff recognise this and care for women in a holistic way to improve the overall experience of having a baby.

Listening to women and families

It is essential that women feel listened to by staff, especially when they are in pain. From April 2024, the first phase of the introduction of Martha’s Rule will be implemented in the NHS. This will allow patients and families to request a review if they feel their concerns are not being listened to. In maternity services, it may help women make sure that their concerns are heard, as during the programme, we were concerned to hear about instances where people felt that staff did not listen to their requests for pain relief. In some cases, this resulted in poor pain management during birth.

The staff weren’t listening to my worry of not having pain relief and managing without an epidural with my mental health as well as my physical health. By the time the midwife took me over to the room, my labour was unbearably painful, and I was told that it was too late for the epidural. I gave birth with no pain relief – not even paracetamol and I was very disappointed and frustrated that they didn’t listen to me when I knew what my body was going to do.

I was not listened to by the healthcare professionals during my labour and they were not managing my pain. I was left for several hours despite asking for help.

One woman we spoke with felt her concerns about pain may have been dismissed because staff knew she had not given birth before:

When I first went into labour I contacted [name of hospital] for advice. I contacted them 4 times as I was in agony with the pain but was told to stay at home because it was my first child. I felt I had been stereotyped because it was my first child and didn’t know how much pain I would be in. When I eventually arrived at hospital after deciding just to go in because I was in so much pain I was actually 7cm dilated.

Even when women asked for help to manage their pain, they were sometimes not given the help they asked for. Through our research interviewing midwives and obstetricians from ethnic minority groups, we heard how false beliefs around physical characteristics and symptoms can mean some people are denied pain relief. Interviewees reported hearing racial bias in pain assessment, for example:

Black women have thicker skin, so they are less likely have a tear after delivery.

You are African, you are tough – you don’t need pain relief, get on with it.

Stereotyping and a lack of cultural awareness can significantly affect people’s experience of care, as we outline in the section of this report on inequalities.

People whose first language is not English face additional inequalities. Access to and the quality of interpreting services varied and continues to be a theme in patient safety incidents nationally. We found some pockets of good practice, for example in one service, the Non-English-Speaking Team (NEST) hosted an antenatal clinic using translation services with midwifery and consultant support. Home visits could be arranged and information was provided in the woman’s first language, allowing people to make the right choice for themselves and their babies.

However, our interviews with midwives and obstetricians from ethnic minority groups highlighted that having poor or no spoken English was associated with worse experiences of care:

My summary is, if you are White you will get good care. If you are not White but you speak English, it’s OK, you will get what you need. If you have poor English – it’s going to be the very basic standard.

This supports the findings of our Safety, equity and engagement in maternity services report. In this, we reported variation in how well maternity services tailored communications and engaged with women whose first language is not English.

NICE guidance is clear that maternity services should ensure that reliable interpreting services are available when needed and that interpreters should be independent, rather than using a family member or friend.

Interviewees also called for staff to do more to ensure that people understand the information they provide:

Staff need to be very mindful that you will get people nodding their head but not understanding. And instead of just choosing to accept that, staff need to make sure that they have understood.

Communication between staff

Multiple studies have shown a link between effective communication and safety in maternity services. Teamwork, co-operation and positive working relationships combined with effective co-ordination are also 2 of the 7 features of safe maternity services identified in research by THIS Institute. Where staff communicated effectively, people told us this had a positive impact on their experience.

My second midwife [name] was brilliant, I witnessed a team who worked seamlessly together, handing over information about my care which made me feel confident in the continuity of the high standards of care I was receiving.”

On all our inspection visits we reviewed the quality of communication and co-ordination at morning multidisciplinary handover meetings on labour wards. These meetings are critical for staff to understand how to manage current risks across the unit. They are also an opportunity for staff to share learning.

A small number of women explained how poor staff handovers had a detrimental impact on their care – notably access to pain relief:

The lack of continuity of care was also a contributing factor to my difficult delivery and eventual caesarean. There was little handover between most clinicians during my delivery and no handover between 2 clinicians, this also led to difficulties and unnecessary pain.

There was no consistency of care during labour. I had the gel and my contractions were really painful and I could tell that the baby was on the way. The midwife wasn't listening to us and actively put off examination due to a change-over of staff.

We also heard from several people who had to repeat information about their medical history, or preferences about their care because of a disconnect between staff:

I saw a different doctor from the diabetic team for every appointment, so I had to tell each one my history.

There was also a disconnect between consultants, midwives and obstetricians, all of whom seemed to have a different opinion on induction timings.

NICE published guidance on information sharing during the postnatal period. It states that when women are transferring between services, relevant information should be shared between healthcare professionals to support their care.

Informed choice and consent

It is essential that women are clear about the risks and benefits of different birthing choices and treatment options. Staff also need to ensure the language they use is accessible so that women know what to expect when they consent to procedures and examinations. Everyone has a right to physical autonomy and integrity, and good communication is vital in empowering people to make informed decisions about their care.

When we found good examples of communication and information-sharing, women praised clear and transparent explanations from staff, which meant that they were able to make more informed choices:

My husband said that the day my son was born, the maternity department was very busy but I was completely oblivious to this as not one midwife or doctor made me feel like this, I felt like everyone gave me the time I needed and we were able to discuss options, ask questions and make plans about our care.

I had loads of questions and anxieties regarding pain relief and labour, and they were able to answer all of my questions and made me feel at ease. I felt as though I was in good hands.

However, this was not always the case. For example, one person told us about feeling a lack of choice about being induced:

I was induced. It did feel as though I was being ‘told’ that I had to be induced. When I expressed my reluctance for an induction a consultant was sent to speak to me. It would have been more helpful to understand the clinical rationale and risk vs benefits of induction versus waiting. The only explanation I received was that ‘baby is to term and it won't affect baby being born early’. I felt this could have been explained more thoroughly and would help me to make an informed decision rather than feeling ‘forced’.

In our interviews with midwives and obstetricians from ethnic minority backgrounds, staff identified other factors, along with language barriers, which can lead to a lack of choice. This included cultural perceptions of authority, where people from some ethnic minority groups may be more inclined (or perceived by staff to be more inclined) to accept the advice of health professionals without questioning it. Concerningly, interviewees also suggested that staff may not always offer choice, because they know they will not be challenged. Perhaps most worryingly, we also heard about perceptions around who is ‘entitled’ to care, and this sometimes affected the level of choice offered.

In our Safety, equity and engagement in maternity report, we found many services had worked together with the Maternity and Neonatal Voices Partnership (MNVP) to engage their local community, including reviewing communications and online content. We were encouraged to see evidence through our inspection programme that this has continued. We found some services worked with local MNVPs to improve informed choice and consent by co-producing information on induction of labour including leaflets and information videos.

Accessing digital maternity records

In line with recommendations in NHS England’s 3-year delivery plan most services have adopted digital records and have maternity records apps to enable women to view their records at home. We heard a few positive comments about the functionality of the maternity records apps and how it contributed positively to the maternity experience as people could access their records, store their birth plan and receive reminders about upcoming appointments.

However, a small number of women discussed their frustration with the maternity records app. For example, we heard that when it was not updated, this meant there was insufficient information about their antenatal care and tests. This could lead to miscommunication and anxiety where test results were only communicated through the app if midwives and nurses remembered to release the information:

The [maternity records app] does not update and let patients know about the care and tests they have received. This left me very anxious during my first few appointments and being pregnant for the first time.

The use of digital technology is not always inclusive. In our Safety, equity and engagement in maternity report, and through our engagement with MNVPs, Five X More and National Maternity Voices, we heard concerns that reliance on digital technology to engage women and provide them with the information they needed could exclude women who do not have the access to, or skills to use, digital technology.