Kemi Birthjoy Johnson

You want to know why maternity care can feel so fragmented, and why women often struggle to get answers after harm? This is one of the reasons. A woman experiences one pregnancy. From the moment she sees a positive test until the day she gives birth, it is one continuous journey. One body. One baby (or babies). One story. She expects the NHS to see it the same way. But maternity services don't. Pregnancy is divided into separate services, departments, pathways, policies and guidelines. • Early Pregnancy Unit • Community Midwifery • Antenatal Clinic • Day Assessment Unit • Labour Ward • Postnatal Ward • Community Postnatal Care Each area has different teams, different documentation, different policies and different responsibilities. Not one continuous process or care. Which immediately stands out to women. Most midwives only see a woman for a brief snapshot of her pregnancy. Perhaps once at 32 weeks. They assess her, review the notes, complete the required documentation and hand her care back. The woman still sees one pregnancy. The system sees separate episodes of care. When tragedy happens, the woman naturally wants answers from the beginning of her pregnancy to the end. She wants truth, where it all went wrong and could she have done anything different. Most women self blame almost immediately. But investigations often examine whether each professional followed the policy or guideline that applied during the specific part of the pathway they were responsible for. If everyone can demonstrate they followed policy and documented their actions, individual accountability may become much harder to establish—even when the overall outcome was catastrophic. That is why women and midwives can leave the same pregnancy with completely different perspectives. Women remember the journey. Midwives remember the stage of care they were responsible for. Until we stop viewing pregnancy as isolated episodes and start seeing it as one continuous journey, we will continue to miss opportunities to understand where care truly failed.

🚨 3 members of midwifery staff whistleblew at University Hospitals Plymouth NHS regarding 2 separate baby deaths & 2 separate data breaches. All 3 are now unemployed 👀 we call for an URGENT independent investigation into this trust. @jamesmurray_ldn @nmcnews @MidwivesRCM @Shamaan_SkyNews @SkyNews @BBCNews @GBNEWS @LBC @ArturNadol7566 @PaulaMc007 @KateShemirani @KenZeroHarm @ArunBaksi @BarbarasBack @SBarrettBar @ShtBlackwood @sharrond62 @BasilTheGreat

In Liverpool in 1977, 3,000 women died in childbirth and approximately 30,000 babies died within their first month of life. This was 30 years after the birth of the NHS, at a time when women were told that giving birth in hospital was the safer option. The latest Ockenden report tells us nothing that history hasn't already shown us. The same themes keep emerging: women not being listened to, poor communication, unsafe care, failures to escalate concerns and missed opportunities to prevent harm. The difference today is that these tragedies are less likely to make the front pages one by one. Instead, it often takes an independent review years later to expose the scale of what happened. History has left us the evidence. The question is why the same lessons still need repeating.