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Rhiannon Lucy Cosslett asks why women are so routinely ignored in their maternity care (Belittled, ignored or gaslit – now we know the true cost of not listening to pregnant women, 25 June). Our research on formal reports about women’s poor maternity care identifies various reasons why women are not listened to, and they all start with their accounts being given less credibility because of prejudices held against them.

Gender-based prejudices carry disturbing echoes of historical patriarchal assumptions and myths about the mysteries of female bodies. They lead to women being perceived as anxious, hysterical or irrational, and can result in their symptoms being dismissed as psychological rather than physical, if they are taken account of at all.

This gender bias is compounded for Black and other ethnically non-white women by racial stereotypes. One of these, the belief that women from particular ethnic groups have higher or lower levels of pain tolerance, has the same outcome – inaccurate, mistimed or missing pain relief in labour.

The result of all this is that women’s own “testimonial knowledge”, what they are saying about themselves and their bodies, is seen as unreliable and therefore routinely devalued. After so many inquiries and reports of the ways in which women are undermined as credible partners in their maternity care, much is now known about the extent and depth of their poor treatment.

It is vital now to implement ways to regulate for safer care in a learning healthcare system which recognises the valuable contribution to safe and compassionate care that women’s voices can make. Otherwise, systemic medical misogyny in maternity care will continue to devastate the lives of women and their families.
Prof Sarah Devaney, Dr Victoria Moore and Prof Alexandra Mullock University of Manchester, Dr Laura O’Donovan University of Sheffield

• Tragically, the horrific stories detailed in the Nottingham maternity review will not come as a surprise (More than 500 mothers and babies died or were harmed at ‘toxic’ Nottingham NHS trust, report finds, 24 June). Neither will the familiar list of immediate and essential actions, most of which have not worked in the past because they champion processes over clinical outcomes and serve only to add to the enormous administrative and bureaucratic burden that is choking the service.

However, the most interesting finding was the refusal of over half of the 66 executives and 10 out of the 14 commissioners to take part in the investigation. These are exactly the people who preach transparency and promise to undertake thorough investigations so that lessons will be learned, yet they shy away when the spotlight is turned on them.

It is understandable that this inflames public opinion and fuels the calls for a statutory public inquiry. But I doubt this will provide any answers or help improve the service because, even if forced to testify under oath, many will simply claim they were carrying out orders from the Department of Health and Social Care or NHS England, most will have been promoted several times over, and all will have the excuse of being part of a much wider team structured specifically to dilute accountability.
Lorin Lakasing
Consultant in obstetrics and foetal medicine, London

• It is over 10 years since the Francis report on Freedom to Speak Up in the NHS was published. Yet the Ockenden review on maternity services in Nottingham found “a culture of fear where junior staff were too intimidated to escalate clinical concerns or challenge unsafe decisions” (Nottingham maternity care scandal review: what are the key findings?, 24 June).

When patients raised concerns, staff did not listen or act promptly. Isn’t it time to make senior managers personally criminally liable for allowing a toxic situation to exist that inhibits whistleblowing?
David Lewis
London

• I read the Ockenden review of maternity services at Nottingham University hospitals trust with deep concern and sympathy for all those who have been affected by the sustained, horrendous levels of “care”. After a career at senior levels in health regulation, health and care charities, and organisations seeking to improve leadership of nurses and midwives, sadly I am not surprised by the findings.

There are, of course, midwives who consistently strive for the very best for mothers and babies, often in very difficult and stressful circumstances. But the failings in Nottingham, and in so many previous scandals in maternity care, show deep and enduring flaws in the leadership of so many in the profession, in particular at the most senior levels in health trusts and boards across the UK, and in government departments. For decades, organisations established to improve nursing and midwifery leadership, and those which represent these professions more generally, have failed to recognise the clear challenges, learn from them and deal with them.

The mothers and babies at the centre of the Nottingham scandal were failed by those midwives responsible for their care, who often treated mothers and their concerns with contempt. These mothers and babies, and so many others, have also been failed over the years by ineffective midwifery leadership at every level that has accepted poor care, not dealt with the many tragedies, prioritised protecting the reputation of the professions and organisations over patient care, lacked vision and grip to make the system better for patients, and individually and collectively not protected or stood up for their patients.

Far-reaching and radical change in the oversight, support and leadership of midwifery, and the wider nursing profession, is long overdue and cannot be further delayed.
Simon Gillespie
Former NHS regulator, Cheshire

• After almost 40 years working at the coalface in the NHS, I can confirm that toxic behaviour in staff, whether with patients or colleagues, is the manifestation of severe stress. It is becoming increasingly frequent. The commonest cause I observed for this was understaffing, resulting in overworked nurses and doctors who were generally more than aware that they were delivering sub-standard care. It should go without saying that most NHS staff wish to look after people with kindness, and not behave in a toxic manner.

A few days ago, my daughter, a trainee midwife, turned up at work. There were meant to be 11 midwives working. Only six were present. This is normal. She was dreading her day at work. The UK is extremely short of midwives. In February a report highlighted “inadequate staffing and resources at every level of maternity care”, yet perversely, “31% of midwifery graduates are unable to find jobs”.

The Ockenden report, among other key findings, reports “chronic understaffing … where midwives and doctors were overstretched, exhausted and unable to respond promptly to requests for help”. I pointed this out over 12 years ago. It is so sad that we have walked with our eyes open into this terrible state of affairs.
Dr M Tariq Ali
Oxford

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