Speed read: The NMNI and Nottingham reviews add to the existing body of evidence of human rights violations in maternity services but fail to recognise that solutions must be underpinned by the human rights framework in order to avoid the continuation of catastrophic harm.
Introduction
The final reports of the National Maternity and Neonatal Investigation (NMNI) and Nottingham Review document a maternity system where women and birthing people are not listened to, dignity is not respected, informed consent is undermined, and racism makes care unsafe. These are serious and systemic human rights violations. Yet the framework of human rights is strikingly absent from the solutions suggested in both reports.
Applying this framework requires that recommendations in both reports be reshaped and guides the changes that must be made at every level, from service design to individual interactions – acknowledging that each aspect is inter-connected.
How human rights require us to listen
A golden thread running through both reports is the need to listen to women and birthing people. Yet ‘listening’ is often implicitly conceived as an individual behaviour rather than a systemic obligation. A human rights framework reframes listening as a legal and institutional duty – a key component of our rights to dignity, autonomy, equality and even to life. It requires services not only to hear people’s experiences but to ensure that their decisions are respected, and that their experiences shape recommendations, influence accountability and drive service improvement.
Autonomy
Protecting women and birthing people’s autonomy is a critically important feature of safe, rights-respecting maternity care. Both reports pay lip service to this principle, but subtly undermine it in ways that echo, rather than disrupt, the erosion that occurs daily across UK maternity services.
The NMNI report states that maternity professionals must “balance” the best interests of mothers and unborn babies. This is wrong. Whilst the healthcare professional is required to offer evidence-based information about the material risks and benefits to mother and foetus of recommended treatment and alternatives, the mother is the decision maker. Unborn babies do not have legal rights in the UK, and any suggestion otherwise risks setting us on the Handmaid’s Tale trajectory we see occurring in the US and elsewhere.
This confusion over the healthcare professional’s role continues in both reports via the construct of “shared” decision-making. To repeat, mothers, not maternity professionals, are the decision makers (except in very rare cases where a mother does not have capacity), and any attempt to override a pregnant individual’s decision to refuse recommended interventions, even under the guise of “safety”, is unlawful. For this reason, the NMNI’s statement that there is “no…legal clarity” for healthcare professionals supporting so-called “out of guidance” births (where some aspects of clinically recommended care have been declined) is manifestly wrong.
Equity
We were pleased to see the NMNI report name racism, discrimination and inequality as a critical safety issue, and to set out urgent recommendations to address this. This framing is a necessary (though long overdue) step in the right direction.
However, the recommendations themselves do not go far enough, and will not make services safe or equitable for Black and Brown women and birthing people. As just one example of where an anti-racist, human rights-centred approach requires more, consider the NMNI recommendation to evaluate existing anti-racism training and establish a national minimum standard. Whilst we support this, we continue to call for a coordinated process to decolonise all midwifery and obstetrics curricula, to achieve structural level improvements, alongside inter-personal and institutional change.
Alarmingly, the approach of the Nottingham Review was significantly worse still: it failed to identify a single urgent and immediate action to address racism within the Trust, despite it being named as a particular concern.
Other forms of discrimination and inequity received shockingly little coverage in either report, and acknowledgement of intersectionality was similarly disappointingly limited.
Triage as a case study
One of the urgent actions recommended in both reports was the development of new standards and procedures for triage services. This recommendation offers a compelling example of exactly why a human rights underpinning is so essential. For this recommendation to be able to achieve meaningful positive change, those responsible for reviewing triage services must have the mandate to consider what harms occurring within triage are symptoms of deeper systemic human rights concerns and be able to call these out as requiring further resolution at all levels, rather than being forced into a siloed approach. They must also ensure that any newly established standards and procedures do not inadvertently cause new harms by being drafted in a restrictive way that ignore individuals’ rights to dignity, autonomy, privacy and equality.
Conclusion
The NMNI and Nottingham Review reports expose profound failures within maternity care. Responding to those failures requires more than service improvement. It requires recognition of the harms as serious human rights violations, and the centring of the human rights framework in all solutions, to design and run maternity services that uphold dignity, autonomy, equality and safety, and keep institutions held to account. Without this reframe, the catastrophic harms caused to women and birthing people and their families will continue.