Birth & Delivery

Birth Trauma Inquiry findings – what are the 12 recommendations for change?

Emma Harpham, Editor  |   17 May 2024


This week, the findings of the UK’s first ever public inquiry into birth trauma were published.

The inquiry is not only a first of its kind, but it puts birth trauma and connected issues into the public eye, as well as bringing it squarely onto the political stage.  

Here’s our wrap up of what the report found, the recommendations for change that it has put forward, and some of the responses from those who’ve been impacted as well as professionals in the maternity sector.

This one comes with a little sensitivity warning – we’ll reference some potentially distressing birth experiences below.

The Birth Trauma Inquiry findings

The Birth Trauma Inquiry heard from over 1,300 women and 100 maternity professionals, and found that poor care in maternity services is “frequently tolerated as normal”, and that good maternity care was “the exception rather than the rule”.

There were some pretty harrowing stories shared, revealing a “postcode lottery” of maternity care in the UK, with some women relating experiences of “blood-stained sheets”, “being left lying on the ground in pain” and “ringing the bell for help but no one coming”.

Digging deeper, the inquiry found key themes of inadequate communication, failure to listen to mothers, insufficient informed consent, and a lack of compassion on the part of care providers. 

There was also repeated evidence of absence of pain management, postnatal care deficiencies, breastfeeding difficulties, and occurrences of medical negligence

The impact of COVID-19 was also acknowledged in the report.

Birth Trauma Inquiry

The 12 recommendations for change

As a result, the report has called for a national plan to improve maternity care, including that the government implement a maternity commissioner, who would report directly to the prime minister.

Here are the recommendations for improvement, in a nutshell. We’ve lifted these directly from the report, which you can read in full here.

1. Recruit, train and retain maternity care staff

Recruit, train and retain more midwives, obstetricians and anaesthetists to ensure safe levels of staffing in maternity services and provide mandatory training on trauma-informed care.

2. Provide universal access to mental health services

Provide universal access to specialist maternal mental health services across the UK to end the postcode lottery.

3. Offer a special 6-week check post-delivery

Offer a separate 6-week check post-delivery with a GP for all mothers which includes separate questions for the mother’s physical and mental health to the baby.

4. Roll out a specialist care bundle for OASIs

Roll out and implement, underpinned by sufficient training, the OASI (obstetric and anal sphincter injury) care bundle to all hospital trusts to reduce risk of injuries in childbirth.

5. National rollout of standardised post birth services

Oversee the national rollout of standardised post birth services, such as Birth Reflections, to give all mothers a safe space to speak about their experiences in childbirth.

6. Ensure better education on birth choices

 Ensure better education for women on birth choices. All NHS Trusts should offer antenatal classes. Risks should be discussed during both antenatal classes and at the 34-week antenatal check with a midwife to ensure informed consent.

Birth Trauma Inquiry 12 recommendations

7. Respect mothers’ choices

Respect mothers’ choices about giving birth and access to pain relief and keep mothers together with their baby as much as possible.

8. Better support for birth partners

Provide support for fathers and ensure nominated birth partner is continuously informed and updated during labour and post-delivery.

9. Provide better continuity of care

Provide better continuity of care and digitise mother’s health records to improve communication between primary and secondary health care pathways. This should include the integration of different IT systems to ensure notes are always shared.

10. Extend the time limit for medical negligence litigation

Extend the time limit for medical negligence litigation relating to childbirth from three years to five years.

11. Commit to tackling inequalities in maternity care

Commit to tackling inequalities in maternity care among ethnic minorities, particularly Black and Asian women. To address this NHS England should provide funding to each NHS Trust to maintain a pool of appropriately trained interpreters with expertise in maternity and to train NHS staff to work with interpreters.

12. More research on the economic impact of birth trauma

NIHR to commission research on the economic impact of birth trauma and injuries, including factors such as women delaying returning to work.

Birth Trauma Inquiry findings

The response 

The response to the Birth Trauma Inquiry reveals a mix of welcome reception, emotional support, and calls to action for further discussion. There’s a sense of urgency, and hope for significant improvements in maternity care in the UK. 

Both the NHS and the UK government have released statements affirming their commitment to positive change. Health Secretary Victoria Atkins, who has previously shared her experience of giving birth as a type one diabetic, said she was “determined to improve the quality and consistency of care for women throughout pregnancy, birth and the critical months that follow”.

However, many also feel that the recommendations simply don’t go far enough and that some of them – particularly the OASI bundle mentioned under recommendation number 4, and the provision of appropriately trained interpreters to tackle racism in maternity care under recommendation number 11 – don’t get to the root of the problem, or safely and inclusively address the real issues at all.

Difficult births are a shared reality for some of us on team TRB, and we aim to be a safe space for any thoughts or feelings that might come up after reading this wrap up. 

Feel free to DM us over on Instagram if you have any questions.

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