The Care Quality Commission’s (CQC) recent national review of maternity services describes how toxic interprofessional cultures are impacting on quality of care. Multiple inquiries have found that poor multidisciplinary teamwork during childbirth causes delays in emergency intervention, as well as birth trauma, with recommended change slow to come. Lord Darzi’s recent report on the wider NHS, which describes the “succession of scandals and subsequent inquiries into maternal care”, suggested that deeper conversations may need to be had on issues such as culture in maternity services.
This blog describes some of the professional culture dynamics in maternity services, why it matters when they clash, and suggests how focusing on our shared values can help us move towards resolution. We should not shy away from a problem because it is difficult to solve.
What is the problem?
Birthing choices are associated with a range of highly emotive beliefs, cultures and philosophies. Inevitably, these ideologies interact with and influence maternity care. Midwives and doctors aim to work together to deliver high-quality and safe care to women and babies, but a clashing of birth philosophies can create dangerous and toxic cultures. “Physiological birth” is often associated with midwives and “medical birth” with doctors – creating a culture war with families caught in the crossfire.
Physiological birth philosophy is centred around the belief that fewer interventions mean fewer complications and a more empowering birth, with non-medical support complementing this – waterbirth, aromatherapy, active birth. Medical birth focuses on reducing the risks of maternal and neonatal mortality and morbidity, developing and implementing monitoring and interventions to help make the birth safer.
This divide in philosophy starts in education – both during training and post qualification. Midwives are trained to be autonomous when birth is physiologically normal, and obstetricians to be the specialists when complications arise, which sometimes leads to power struggles.
It isn’t as simple as midwives versus doctors
Our wider societal values can influence our feelings around giving birth. Some feel they have failed for choosing an epidural, feel judged for going outside of medical recommendations, or selfish for desiring more than just a healthy baby – perhaps also hoping for a transformative experience whether that is through a planned caesarean or drug-free waterbirth.
Place of birth – home, birth centre or hospital – can also be seen as controversial, with midwives sometimes caricatured based on their work settings. I’ve experienced this first-hand working as a midwife, having to fight to justify emergency transfers between midwifery-led and obstetric-led units. My clinical judgement around the need and timing of transfer was viewed sceptically by colleagues working in different areas. This lack of trust, based on beliefs rather than competence, brings the risk of dangerous delays.
Why does this matter?
Stories of women and birthing people denied pain relief and planned caesarean sections, or pressured into unwanted invasive procedures, have become commonplace. Inquiries of the biggest scandals have revealed that babies’ lives could have been saved if there had been earlier escalation of care from birth centre to hospital.
Unacceptably, people from deprived and minority communities are disproportionately affected by these tragedies. Black, Asian and mixed ethnicity women report experiencing racism from their caregivers, and are more likely to be ignored, disbelieved, offered less information and coerced into decisions.
When professional becomes personal
Having been a midwife for many years before becoming pregnant, I was acutely aware of challenging workplace cultures created by different birth philosophies. However, I was relieved that when it came to my son’s birth, these approaches worked in harmony to keep me and my baby safe, empowering me to start motherhood in the best way possible.
I had the medical pain relief I wanted, alongside aromatherapy and my questionable playlist. Squatting, I lifted my son up as he was born, knowing I had a doctor by my side, called by a concerned midwife, in case she had been needed. I was grateful to the team of neonatal staff who expertly resuscitated my baby, then invited my husband to discover the sex of our newborn.
My son’s birth – shaped by privilege and luck – demonstrates that medical intervention and holistic care can be blended to reach the best possible outcome. Reviews of maternity care have found good practice alongside the failings. How can we learn from the good and address the bad?
Moving forward: finding shared values
Recommendations to improve teamwork have focused on learning from services where different professions train together, improving leadership and ensuring teams have a shared purpose. The Royal College of Midwives abandoned their “campaign for normal birth” – which called for fewer medical interventions in childbirth – and instead launched the Re: Birth project, which bridges divides by helping colleagues find a shared language for birth.
Culture wars thrive when opposing sides become entrenched. It is important to learn from successful culture shifts, and psychologically safe spaces where people can listen and empathise with each other can facilitate change. Recent calls for shared and quality break spaces may help this, but as inquiries and THIS institute’s “For Us” framework have highlighted, focusing on common goals is essential to having productive conversations.
When we are forced to take sides, we fight to defend the position we are coming from. When we find shared ground we can move towards solutions together, even if the way we would personally have chosen to get there is different.
The image below shows the differing key beliefs of two main birth philosophies, and the important core values they share, such as prevention of bad outcomes, health equity, dignity and respect, informed choice, and high-quality care. While the mutual values highlighted may seem obvious, they can be lost when conflict arises. By focusing on what is shared, instead of differing beliefs, women and birthing people are put back at the centre of their care – with quality, safety and informed choice the common goals.
But how do we make this happen in practice? A good start would be teaching shared maternity values in midwifery and medical education, setting professionals up for a collaborative future. NHS trusts need to practically embed co-designed and shared values, so that when conflict arises these can be used to refocus clinicians’ minds on what is best for the family. However, developing values is not enough on its own – maternity leaders need to embody them, integrate them into debriefs and training, and address behaviour that does not align to them.
My hope is that the belated, much-needed change in maternity services will be that bit easier if, instead of fixating on what separates us, we remember what unites us.
*Look out for our upcoming explainer, which will summarise some of the wider issues facing maternity care and the efforts underway to encourage change.
Suggested citation
Best R (2024) “Professional culture wars in maternity: we should focus on shared values, not differing beliefs”, Nuffield Trust blog