Blood Doesn't Lie: Warning Signs and Lessons from Britain’s Maternity Crisis

Earlier this month I spent several weeks in the UK and took the opportunity to meet with some key individuals in British maternity and health care.

During a visit to Westminster, I had the privilege of meeting with two Members of Parliament who also happen to be doctors: Dr Zubir Ahmed MP, a vascular surgeon and former UK Health Minister, and Dr Simon Opher MP MBE, a general practitioner with experience in obstetrics and gynaecology.

Although we practise on opposite sides of the world, we found ourselves asking remarkably similar questions about one of the greatest challenges facing modern maternity care: how do we know when a maternity service is beginning to fail?

It is tempting to search for complex answers. Perhaps, however, one of the simplest indicators has been sitting in front of us all along.

Blood.

A vascular surgeon naturally views healthcare through the lens of blood loss and vascular physiology. Looking at maternity through that perspective was enlightening. Many of the most devastating maternal and neonatal outcomes are closely associated with postpartum haemorrhage. Emergency hysterectomy. Massive transfusion. Difficult operative birth. Severe perineal trauma. Fetal compromise following prolonged labour. While these outcomes have different immediate causes, blood loss is frequently part of the same clinical story.

Correlation is not causation. However, when correlations become consistent across thousands of births, they deserve attention.

Blood products are measurable. They are routinely collected. They are available almost in real time. Unlike many complications of childbirth, which may not become apparent until months or years later, blood transfusions provide an immediate signal that something has gone wrong.

This raises an important question.

Could blood product utilisation become one of the simplest early warning indicators of maternity unit performance?

If a maternity service is consuming significantly more blood products than comparable units after adjusting for case mix, should we be asking why?

The scale of what earlier signals might have caught became clear this year when the Ockenden Review into Nottingham University Hospitals found that more than 500 women and babies had experienced potentially avoidable harm or death. Women's concerns were dismissed, clinical deterioration was missed and escalation to specialists was delayed. A measure like blood product utilisation would not have prevented every case but it is exactly the kind of signal that might have prompted scrutiny long before harm reached that scale.

That question becomes even more important when we consider that the long-term consequences of poor maternity care often remain hidden. Pelvic floor injury, urinary and faecal incontinence, chronic pain, prolapse and lifelong neurological injury to babies may take years to fully emerge. By the time litigation occurs, the opportunity to prevent harm has long passed.

Our discussions also turned to culture.

Guidelines continue to evolve, as they should. Labour management has changed substantially over recent decades, including the adoption of modern labour curves and revised expectations regarding normal labour progression. Evidence should always evolve. However, evidence alone does not improve outcomes.

Implementation does.

The safest maternity services are characterised by strong governance, clinical leadership, compliance with evidence-based practice, multidisciplinary teamwork and a culture that welcomes review rather than resists it.

Later, in my meeting with Dr Simon Opher MP MBE, we explored another important principle. Doctors care deeply about patient experience but our responsibility extends beyond the individual consultation. Clinicians have an equally important role in designing safe healthcare systems. Good systems do not arise by accident. They require thoughtful policy, evidence-based guardrails and governance that continually asks whether patients are genuinely safer today than they were yesterday.

The national Amos investigation, which examined maternity and neonatal services across twelve NHS trusts, found much the same thing from a different angle: capacity pressures, fragmented systems and care decisions shaped by available resources rather than clinical need. Good intentions were not the problem, it was the absence of systems designed to catch failure early.

Australia should pay close attention to that lesson, not because our system has failed in the same way but because some of the same conditions are forming.

Current policy development strongly promotes midwifery continuity, while proposals for bundled maternity payments could place a single non-medical provider at the centre of care.

Continuity of care is valuable but it is not a substitute for properly staffed multidisciplinary teams, early specialist involvement and clear escalation pathways. The National Maternity Workforce Review must not become a vehicle for expanding one profession while overlooking the obstetric, anaesthetic, paediatric and general practice workforces required to keep services safe.

One of the most insightful conversations of my visit was not with a politician or a clinician, but with Catherine Roy. We spent more than four hours discussing the evolution of maternity care in the United Kingdom and the lessons it offers internationally. Catherine has dedicated years to understanding why she and the women in her mothers' group felt so profoundly betrayed by a model of care that promised birth would be "normal", only for many to experience outcomes that were anything but. That personal experience has driven an extraordinary commitment to understanding how the UK maternity crisis developed.

Through meticulous research, Catherine has become one of the most knowledgeable voices on the history of the UK's maternity system, documented in her book, Maternity: An Ongoing British Scandal. It provides an exceptional account of how ideology progressively influenced maternity policy, how evidence-based medicine became increasingly sidelined and how many within the medical profession found themselves unable or unwilling to challenge changes that conflicted with the fundamental principle of primum non nocere: first, do no harm.

The lesson generalises well beyond the UK. Consumer participation in maternity policy is essential. It becomes dangerous, however, when the loudest voices recast medical involvement as unnecessary intervention rather than a safeguard. Lived experience should inform policy but it cannot substitute for clinical evidence, transparent outcome data or balanced professional expertise.

Outside of conversations with fully qualified specialist obstetricians and gynaecologists, I have not previously met anyone able to articulate the history, policy evolution and clinical implications of the maternity crisis with such depth, accuracy and clarity. Her work is an important reminder that meaningful reform requires clinicians, policymakers and informed consumers to work together, grounded not in ideology, but in evidence, transparency and an unwavering commitment to patient safety.

I highly recommend Maternity: An Ongoing British Scandal, for anyone who wants to learn what has happened in the UK and what we need to be aware of in Australia.

Australia and the United Kingdom are facing remarkably similar challenges. Workforce pressures, rising intervention rates, increasing litigation costs and growing demands on maternity services are not unique to a single nation.

Neither are the solutions.

As President of NASOG, I remain convinced that maternity policy must become increasingly data-driven. We need meaningful outcome measures that identify deteriorating performance early, support clinicians to improve practice and ultimately prevent avoidable harm before families are left living with its consequences.

Blood may not tell the whole story.

But sometimes it tells us enough to know where we should begin looking.

Dr Elizabeth Jackson

Specialist Obstetrician Gynaecologist (Fellowship attained 2016), MBBS, NASOG, MReproMed, MMIS, MBA, CAICD

President, National Association of Specialist Obstetricians and Gynaecologists