The Ockenden Review

The review, chaired by senior midwife Donna Ockenden, uncovered a pattern of repeated serious harm to mothers and babies. The report looked into 250 cases – out of nearly 2,000 identified between 2000 – 2019 – and has called for urgent and sweeping changes to improve safety in maternity services for the trust and across England.

Here are some of the report’s key findings:

Lack of kindness and compassion 

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The review found the ​“lack of kindness and compassion” displayed by members of the maternity team. Some parents who had lost a baby were offered no words of condolence; one mother said the trust’s bereavement service made ​“it so many times worse”. The report said: ​“Inappropriate language had been used at times causing distress”, and there were cases ​“where women were blamed for their loss and this further compounded their grief”.

Reluctance to conduct caesarean sections

Caesarean section rates at the trust have been between eight per cent and 12 per cent, consistently below the English average of 24 per cent. The review found a culture of trying to keep c-section rates low because of a belief that this demonstrated good maternity care. But the review found earlier decision to use caesarean delivery would have avoided death and injury in many cases.

Maternal deaths

The review found that 13 women died in childbirth between 2000 and 2019, which is disproportionately high. It found a lack of planning in the care for women with underlying health problems, resulting in delays that proved fatal in their treatment. The reviews into these deaths also lacked ​“rigour and quality”, meaning that ​“no learning appears to have been identified”. While the report said the women were often correctly identified as being ​“high risk” due to existing medical conditions, little action appeared to follow.

Blaming mothers

Hospital reviews of serious cases were sometimes ​“cursory”. The trust failed to identify underlying failures in care, and sometimes blamed mothers. Letters and records around cases were found to have ​“focused on blaming mothers rather than considering objectively the systems, structures and processes underpinning maternity services”. The review said: ​“There are several examples where mothers say that they were made to feel responsible by trust staff for the loss of their babies.”

Over-use of oxytocin

Oxytocin, a drug used to increase contractions, was often used too frequently in labour despite the known risk it posed to fetal heart rate. 

Traumatic births

The review found evidence in several cases of ​“repeated attempts” at delivery with forceps, sometimes ​“using excessive force, all with traumatic consequences”. 

The review has rightly responded by requiring seven ​“immediate and essential” actions to be made for all maternity services across England. Additionally, the report lists 27 actions the trust must carry out immediately.

Pray

Firstly, as with all things, we must pray. Pray for those families that have suffered indescribable loss. Pray for those working in maternity services who have done nothing wrong, and yet may feel tarnished by this review. Pray that there would be real substantiative change in maternity care where it is clearly needed. Pray that the Lord may use this darkest of situations to bring people to Himself. Pray that people would consider the value of unborn life to an extent they have perhaps not before now.

Be a voice for the voiceless

As the details of this report have been revealed, the country has been enraged and horrified at the treatment of parents and their children, both the delivered and the unborn. As children of the living God, we believe that all life is ​“fearfully and wonderfully made”, known and loved by God before we were formed in our mother’s womb, and that all humans are made in the image of God, of equal value. This means that when life is lost, taken, and neglected to the point of death, we should be heart-broken, just as our Father is heartbroken. There is a just anger to be felt, and we can connect with our friends and families who don’t yet know Jesus over these destroyed lives.

Have conversations around this issue and share what motivates your distress. Share the belief that God designs and creates every human life and how that means their value cannot be understated. Common ground can surely be found in this situation around the tragedy of the lost unborn life. Perhaps, in God’s grace, this might lead to wider conversations about when that life begins. Perhaps walls will fall down that try to distinguish when the loss of the unborn goes from being a tragedy to a freedom of choice.

Share hope for a day without death

“‘He will wipe every tear from their eyes. There will be no more death’ or mourning or crying or pain, for the old order of things has passed away. He who was seated on the throne said, ​‘I am making everything new!’” (Revelation 21:4 – 5)

We are free to grieve, but as Christians we grieve with hope. The world knows no greater fear and sadness than that of death – particularly when it appears unexpectedly – as with babies. But we know the one who sets us free from death’s grip. Jesus died once for all, so that those who trust Him may never know death’s true sting. God’s plan for restoring the world into His new creation is utterly beautiful and compelling. As we once again are faced with the reality of death in the world today, hold on to this hope, and hold it out for others, that they may know it for themselves.