The juxtaposition of existing as a labour ward midwife and birthing mother; my thoughts on institutional power and dangerous workplace cultures in maternity services

Lily is a midwife and mother pursuing a PhD focused on consent in labour. She left the NHS to focus on her PhD and her work offering rewind therapy to women and birthing people who have experienced birth trauma.

Here, she reflects on her experiences of power and workplace cultures within maternity care.

@theethicalbirthinstititute @_lilyhutton

The deeply harrowing interim report by Baroness Amos has highlighted what many women, birthing people, families and staff working within the birth sphere have known for a long time. There are well-known systemic failures within maternity care, and there has been little investment in creating real change for birthing people and their families despite longstanding reports of harm (Amos, 2025).

The convergence of power dynamics, hierarchies and workplace culture is well documented to negatively influence communication between teams, reducing team effectiveness and contributing to poor outcomes across healthcare as well as within maternity services (Kearns et al., 2021; Elliott-Mainwaring, 2021).

This blog details a midwife’s personal reflection on power and toxic cultures in maternity care, which contributed to a decision to leave the NHS and pursue a full time PhD, in the hope of contributing research which aimed at improving services for all women and birthing people.

Power, culture and inequality in maternity care

It is no secret that workplace cultures in maternity care can contribute to harms affecting both service users and staff. The CQC published a report on the current state of maternity services in England in September 2024 and documented concerns that some of the potential harms to women, birthing people and babies may have become so ingrained within some workplace cultures that staff may no longer recognise them as a potential harm (Care Quality Commission, 2024). Workplace culture and divide between doctors and midwives have also been specifically highlighted during investigations into failures in NHS Trusts (Ockenden, 2022).

Midwives have reported feeling the dual responsibility to provide woman-centred care, and ‘negotiate’ with the wider MDT to balance tensions (Feeley et al., 2020, p14). These tensions included arguments between professionals, with midwives being labelled as ‘putting women in danger’ and a strong feeling among midwives that advocacy for their clients within obstetric appointments was necessary (Feeley et al., 2020, p.15). However, it is possible that the friction between different professionals is furthering harm and more recently, staff within the NHS are advocating for shared values between the professions to improve care and outcomes (Best, 2024).

The law and professional guidance is indisputable. Regardless of whether women and birthing people are midwifery or obstetric led, decisions regarding their care should be shared; with information, research and preferences being communicated freely between all parties (NMC, 2018; GMC 2024; Montgomery v Lanarkshire Health Board, 2015). Maternity care should therefore exist in an environment that empowers service users to be involved in choices regarding their care, with active attempts to diminish power dynamics between the different professionals and women and birthing people.

Despite this, growing research into women’s and birthing people’s experiences of maternity care shows that decisions about birthing bodies and care plans are often controlled primarily by healthcare professionals (Birthrights, 2013; McLeish & Redshaw, 2019), potentially creating environments where cultures of coercive and dismissive care have the opportunity to thrive. These experiences are likely to be intensified for women and birthing people who face additional barriers to equitable care, including but not limited to those from minoritised ethnic groups and those affected by disability, gender identity, or sexual orientation (Jomeen & Redshaw, 2012; Blair et al., 2022; Sheriff, 2025).

It is therefore important to acknowledge the existence of cultures, which may have become standard practice in some areas, to examine their root cause and to focus on redistributing the power between professionals to diminish hierarchies between healthcare staff. Most importantly, ensuring that women and birthing people have overall control and power over their choices regarding their pregnancy and birth.

The history of birth and why it matters

Similarly to wider medicine, obstetrics has roots in misogyny and racism. Alongside the medicalisation of childbirth, which commenced in the 18th century, ideas of ‘doctor knows best’ and linking women’s mental health to hysteria- a disease of the womb- obstetricians and gynaecologists often performed procedures on women and birthing people with minimal pain relief or choice (Davidson 2020). This extended to a doctor performing experimental operations on Black slave women in America without their consent following complications from childbirth- Anarcha, Lucy and Betsey- and despite committing ethical atrocities, still being recognised as the ‘founder of modern surgical gynaecology’ (Wall, 2006, p.346).

The medicalisation of childbirth continued into the 20th and 21st century; as birth moved out of the home and into hospital (Nove et al., 2008), caesarean section rates increased, and fear of litigation emerged in practitioner advice and decision making which began overruling patient choice (Kessler et al. 2006). Feminist writers through this time related women’s bodies within the medical model of childbirth to machine equipment and mechanical objects, which men felt needed to be adjusted and fixed (Oakley, 1989) .

These attitudes, along with racist and misogynistic undercurrents, can still permeate modern care. Most notably, it is likely that healthcare professional’s internalised biases contribute to the inequality reported in maternal death of between Black and Brown women compared to white women (MBRRACE-UK, 2025). Language is also a common vehicle for expressing these biases, as women have reported being addressed as “good girl” or “silly girl” during labour (Benzon et al., 2024). This type of language reinforces power dynamics between women, birthing people and healthcare professionals, further disempowering them from being actively involved in their care.

The history of birth has the potential to contribute to modern practices. Despite societal change and a shift to the importance of woman-centred care from an ethical and professional perspective, evidence of misogyny and racism still exists. It is important to actively work against this to provide more equitable care and improve physical and psychological outcomes for women, birthing people and their families.

Holding space: reflections from practice

As a midwife, I felt a strong tide of institutional power and conformity; praise for quick transfers from labour ward to postnatal ward, despite women and birthing people still wanting one to one support with breastfeeding and being concerned about visiting the shower or toilet without professional support. I also felt demonised for being emotionally burned out, with more seasoned staff explaining ‘we couldn’t take days off for our mental health back in my day’. I wanted desperately to provide better, more individualised and supportive care, for women and birthing people, but I didn’t feel that the system gave me the space to do that.

The importance of following guidance was stressed as a safety measure. I deeply believe in the education of women and communicating risk. I too wish to prevent poor outcomes as much as possible, but I believe women should make their own decisions regarding care plans, based on their own perceptions of risk. In contrast, guidance is often uniformly applied as a care plan to many women and birthing people, rather than through individual discussions of the research that contributed to the guidance and how a particular study may or may not apply, to the woman or birthing person in your care.

It began to feel as though I was the motor of a conveyor belt, endlessly looping the same universal advice and plan of care as women moved through the labour ward and onto the postnatal ward, often induced and often receiving multiple interventions.

I met many, many professionals, midwives, and doctors, who were disheartened with the system or too burned out to push back. I know that providers of maternity care often begin their journey into obstetrics or midwifery due to a profound respect at the capabilities of a birthing body, rather than a desire to disrespect it.

However, I felt the evidence had become undeniable; we weren’t getting it right, and things needed to change. I needed to evaluate how I could still contribute to the provision of maternity care, but from a space that not only aimed to improve care for women, birthing people and their families but that promoted mental security for myself.

Good relationships between healthcare professionals improve care for women and birthing people, but you often feel that you disagree with the common practice within this system. You feel stuck. This feeling stayed with me throughout my time in the NHS and I felt increasingly less able to provide the care that I wanted. So, I made the decision to move into research with the aim of undertaking research that could contribute to creating a solution.

From midwife to mother

Being in labour places you in a unique place of vulnerability. When giving birth to my son in 2023, I experienced how the undercurrents of power can encourage you to make decisions that you are actively against outside of giving birth. On reflection, I was confused with my own choices, but even as a loud and passionate midwife, I felt it was almost impossible to disagree with the plan of care they laid out for me. This made me realise that we encourage women to agree to our plans of care with the language that we use, asking, ‘This is the next step, is that okay?’ which lacks true shared-decision making and involvement in care.

Birth was also a blunt reminder that as professionals our body language and lack of foresight into the way in which a woman or birthing person’s body may be so vulnerably positioned may further encourage them to be complicit in our care plans, rather than active participants. Many questions were asked and decisions made while I was naked with my legs astride. It is almost impossible to engage in decision making when you are so physically vulnerable, and we must work harder to give women the time and space following intimate examinations to make choices about their next steps.

We must be more thoughtful in our practice, working harder to maintain dignity for a woman or birthing person when asking them questions about the plan of care. We must present information in a way that offers true choice, rather than simply communicating a plan and giving space for push back. This only reinforces existing power dynamics and makes women-centred care and shared decision making more difficult.

Restoring voice, choice and trust

I strongly believe that more research is needed to explore how women and birthing people would like their care improved, so that service users can shape a better maternity care system. This should be done through interviews and in depth focus groups with women, birthing people and their families, rather than via tick box questionnaires for preferences. Professionals require more training regarding language in conversations around interventions during birth so that they can improve in creating space for women and birthing people to discuss their thoughts and feelings, as well as providing a deeper analysis of the risks and benefits if this is the level of risk disclosure the birthing person chooses. There is no other profession within medicine like obstetrics. I believe more emphasis should be placed on an understanding of the cultural power which professionals hold over their service users and how this is further amplified within a maternity setting so that we can actively work against it and assign power where it belongs, with women and birthing people.

There are clear issues with power dynamics, hierarchies and sometimes dangerous cultures within maternity care in the NHS. This is impacting both the physical and psychological safety of women and birthing people and this must change.

If you’re interested in participating in the PhD research, please review the ‘Live Research’ page on the Make Birth Better website, where you can access more information.

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References

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