Reorienting Safety Culture in Maternity Care

Why “Patient Safety” Falls Short and What We Must Do Instead

Introduction: Time for Change

In healthcare, 'patient safety' is a foundational concept (Institute of Medicine, 2000). Preventing harm and promoting high-quality care are essential. In maternity care, the term patient safety is embedded within a medicalised, hospital-centric model that can be at odds with midwifery philosophy and the experiences of birthing women.

We must ask: Safe for whom, and by whose definition? This blog post argues for a shift in safety culture; from a focus on protocols and risk aversion to one that centres each woman’s wellbeing and safety in all its dimensions.

Please note: throughout this blog post, I use gendered language (e.g. “maternal,” “mothers,” “women”) with the acknowledgement that some who give birth do not identify as women.

The Problem with 'Patient Safety' in Maternity Care

The term 'patient safety' emerged from a hospital risk-management paradigm focused on preventing clinical error (Institute of Medicine, 2000). It assumes that the care recipient is ill, passive, and dependent, and that safety is achieved through compliance and protocol.

This framing is a poor fit for maternity care. Childbirth is not an illness. The majority of women are well, and the birthing process, when supported physiologically and respectfully, often unfolds safely without intervention (Consensus statement, 2013).  The term patient strips women of agency, embedding a power imbalance, positioning them as objects of care, rather than autonomous participants. It reinforces a culture where decision-making is top-down and where deviation from protocol is seen as dangerous, regardless of the woman’s values or the context. Safety in this context is too often reduced to physical outcomes alone. While survival is of course paramount, the ‘patient safety’ focus on physical outcomes neglects emotional, psychological, cultural, and relational safety, all of which profoundly impact a woman’s experience and recovery (Bohren et al., 2015).

Consequences of a Misaligned Safety Culture

• Over-medicalisation: Risk-averse environments may lead to unnecessary interventions that increase morbidity and trauma (Birthrights, 2013).
•  Disempowerment: Women may be coerced, ignored, or denied informed choices “for their own safety” (Keedle et al., 2022).
• Moral injury among midwives: Midwives may be unable to practise in ways that align with their professional knowledge and values (Kendall‐Tackett & Beck, 2022)
• Structural harm: Racism, cultural insensitivity, and obstetric violence are often overlooked in traditional safety audits (Hailu et al., 2022).

A Midwifery-Informed Vision: Woman’s Wellbeing and Safety

• Holistic: centring the whole person, physical, emotional, cultural, and social (O’Reilly et al, 2025).
• Embracing partnership and informed decisions (Esteban-Sepúlveda et al., 2022)
• Valuing continuity of care and trust (Homer, 2016).
• Recognising women’s right to define their safety. (Rönnerhag et al., 2018)
• Safety, in this sense, is not the absence of clinical error: it is the presence of respect, choice, connection, and support (Lyndon et al, 2018)

Practical Steps Toward Reorientation

1. Replace “patient safety” with “woman’s wellbeing and safety.”
2. Value relational safety and continuity of care.
3. Embed emotional, psychological safety and Cultural Safety as essential elements.
4. Foster reflective, non-punitive team cultures.
5. Involve women in defining what safe care means.

Conclusion

True safety in maternity care cannot be achieved by clinging to a model that sees women as patients and care as something done to them. We must shift from a safety culture of control and compliance to one of trust, relationship, autonomy, and respect. Language is not neutral and by choosing to centre each woman’s wellbeing and safety, we take a meaningful step toward care that is not only safer but also more just, more respectful, and more human. Safety in maternity care must move beyond checklists and compliance. It must be woman-defined, relational, and holistic. The term “patient safety” no longer serves us — if it ever did. By reorienting our language and our culture toward each woman’s wellbeing and safety, we honour not only midwifery values but the human dignity of every woman giving birth.

Let us choose our words and our paradigms wisely. They shape the care we give.

What do you think? Do you agree? Do you disagree? 

References

Birthrights. (ND). Human rights in maternity care: the key facts. https://www.birthrights.org.uk

 Bohren, M. A., et al. (2015). The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review. PLoS Medicine, 12(6), e1001847. https://doi.org/10.1371/journal.pmed.1001847

Chauncy, C., Dawson, K., & Bayes, S. (2025). What do safety and risk mean to women who choose to birth at home? A systematic review. Midwifery, 144, 104340. https://doi.org/10.1016/j.midw.2025.104340

 Esteban-Sepúlveda, S., Fàbregas-Mitjans, M., Ordobas-Pages, L., Tutusaus-Arderiu, A., Andreica, L. E., & Leyva‐Moral, J. M. (2022). The experience of giving birth in a hospital in Spain: Humanization versus technification. Enfermería Clínica (English Edition), 32, S14-S22. https://doi.org/10.1016/j.enfcle.2021.10.007

Hailu EM, Maddali SR, Snowden JM, Carmichael SL, Mujahid MS. Structural racism and adverse maternal health outcomes: A systematic review. Health Place. 2022 Nov; 78:102923 https://doi.org/10.1016/j.healthplace.2022.102923

Homer, C. (2016). Models of maternity care: evidence for midwifery continuity of care. The Medical Journal of Australia, 205(8), 370-374. https://doi.org/10.5694/mja16.00844

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington. DC: The National Academies Press. [Link](https://doi.org/10.17226/9728)

Keedle, H., Keedle, W., & Dahlen, H. (2022). Dehumanized, violated, and powerless: an Australian survey of women's experiences of obstetric violence in the past 5 years. Violence Against Women, 30(9), 2320-2344. https://doi.org/10.1177/10778012221140138

Kendall‐Tackett, K. and Beck, C. T. (2022). Secondary traumatic stress and moral injury in maternity care providers: a narrative and exploratory review. Frontiers in Global Women's Health, 3. https://doi.org/10.3389/fgwh.2022.835811

Lyndon, A., Malana, J., Hedli, L. C., Sherman, J., & Lee, H. C. (2018). Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 324-332. https://doi.org/https://doi.org/10.1016/j.jogn.2018.02.008

O'Reilly, E., Buchanan, K., & Bayes, S. (2025). Emotional safety in maternity care: an evolutionary concept analysis. Midwifery, 140, 104220. https://doi.org/10.1016/j.midw.2024.104220

Rönnerhag M, Severinsson E, Haruna M, Berggren I. Qualitative study of women's experiences of safe childbirth in maternity care. Nurs Health Sci. 2018; 20: 331–337. https://doi.org/10.1111/nhs.12558

Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. (2013). The Journal of Perinatal Education, 22(1), 14–18. https://doi.org/10.1891/1058-1243.22.1.14

Why the way maternity care is provided has to change!

You have to read this post!  It clearly demonstrates all that's wrong in contemporary maternity care.

Nathan is leaving the building and he is exactly the kind of obstetrician we need to help stop the madness of modern maternity 'care'.  

He writes: 

The life of a hospital-based OB/GYN is misery. Phone calls throughout the night to fix problems that we created through attempts to induce or intensify birth surges are a prime example of how our priorities have become totally ass-backwards.

Read on ... 

Click the link below to read Nathan's heartbreaking and yet inspiring reflection - he shows clearly what needs to  happen

On my departure from hospital-based birth - a reflection

Modern maternity care has become a self-fulfilling hampster wheel of fear and intervention, becoming more and more disabling for everyone involved.  Nathan nails it.  Let's change it.

We need to move entirely to woman-centred care; let's provide continuity of midwifery care; let's leave things alone until there are signs some help is needed - let's not break women's birth processes and then have to fix them.   Let's not use war metaphors for our practice - women don't need pre-emptive strikes, but they do need loving support, kindness and safe places to explore what becoming a mother means - as does her partner need the same care.

Let's do it and bring back Nathan and all the other Nathans and midwives who leave in disgust at home the system traumatises everyone.

The image below is from Nathan's Blog Post and I thought it apt, very apt ...
 

Maternity Care: Building Relationships Really Does Save Lives - free online course

FREE online course: Maternity Care: Building Relationships Really Does Save Lives.

Griffith University is again providing its highly acclaimed online MOOC

The life-saving, life-enhancing, powerful course was developed by the fabulous Professor Jenny Gamble, Professor of Midwifery and wonderful Associate Professor Mary Sidebotham from Griffith University, Australia in partnership with the brilliant soul-sister midwife, Leanne Schwartz, Director of Deepening the Journey, retreats for midwives and birthkeepers.

Learn how quality relationships between mothers, midwives and other health professionals transform maternity care and save lives.

This next course starts 27 January 2020. It runs for 3 weeks and the volume of learning takes about takes about 3 hours a week.

Research unequivocally shows that providing a woman with the same midwife before, during and after birth, results in less preterm birth, fetal death and other complications.

This course explains why we need relationship-based care in maternity services. You’ll discover how to create successful relationships, and how this produces better outcomes for the mother, baby and midwife.

You’ll learn about organisational healthcare models, and what you and your local community can do to contribute to the transformation of maternity care globally

Professor Jenny Gamble writes: 

If you think that what happens during pregnancy and birth matters. If you're interested in relationship-based maternity care, or if you just want to have the evidence readily accessible: please sign up and join our global movement!

The course is free. If you want a certificate for your records, then you can pay to upgrade your enrolment.

It's a fabulous learning opportunity - with this course, you will get the science behind the facts!

Here's the link Maternity Care: Building Relationships Really Does Save Lives

Thirty years of the World Health Organization’s target caesarean section rate. It’s time to take it seriously.

Australia, like much of the western world faces burgeoning numbers of women having caesarean sections along with increasing rates of postpartum haemorrhage, postnatal depression and other morbidities. There are many who argue for surgical birth, saying childbearing women are older, fatter and sicker and therefore require the life-saving operation. Others are critical of the increase. Then there are those who examine the literature and seek the truth of the matter.

Today's blog post is by Dr Kirsten Small, an Obstetrician and Gynaecologist who teaches in the School of Nursing and Midwifery at Griffith University in Queensland, Australia. 

Kirsten has a research interest in examining the mismatch between the evidence base and what happens in clinical practice in maternity care.

In line with her research interest, Kirsten provides the following thought provoking lens on a recently published review of the World Health Organisation's target caesarean section rate. Read on, I think you'll find what she has to say fascinating.

The Medical Journal of Australia recently published a narrative review, titled “Thirty years of the World Health Organization’s target caesarean section rate: It’s time to move on.” (link: https://www.mja.com.au/journal/2017/206/4/thirty-years-world-health-organization-s-target-caesarean-section-rate-time-move).

Authors Stephen Robson and Caroline DeCosta argue that the “ideal” caesarean section (CS) rate proposed by the World Health Organization in 1985 is “too low” (Robson & DeCosta, 2017, p 184).

By selective use of published literature, they generate a narrative to support this argument, and somewhat obtusely recommend that “in Australia, we should be aiming to provide CS to all women in need” (Robson & DeCosta, 2017, p 184). It is difficult to disagree with this point, but the high Australian CS rate would suggest that we are also providing CS to women who have no need for it, and who may not desire it.

The key points of their paper are presented in a summary as Figure 1 below. 

 Figure 1: Summary Robson & DeCosta, 2017, p 181

It is possible however, to use the published literature to create a different narrative, one that supports the contention that Australia’s CS rate is not appropriate.

An alternative summary of the evidence is:

• It has been two years since the WHO reaffirmed its longstanding position that the ideal CS rate is under 20% (Betran, et al., 2015).
• CS rates, particularly in wealthy industrialised countries continue to rise, with no evidence of associated improvement in perinatal outcome (Betran, et al., 2015)
• The strongest predictor of CS birth for the first infant is birth in a private hospital (Dahlen et al., 2012).
• Women whose first baby is born by CS find it difficult to access a care provider who will support them to achieve a vaginal birth in subsequent pregnancies (Toohill, Gamble, & Creedy, 2013).
• Outcomes that interest the patriarchal medical model typically exclude those that reflect women's experience of their care (Parry, 2008).
• Longer term outcomes for the neonate are better following vaginal birth rather than CS (Hyde, Mostyn, Modi, & Kemp, 2011).
• Pelvic organ prolapse and incontinence are not strongly correlated with mode of birth (Bozkurt, Yumru, & Şahin, 2014). Surgical procedures for these conditions are increasingly safe and carry low risks of complications (Ogah, Cody, & Rogerson, 2011).
• Serious complications of CS such as placenta accreta, while rare, are of increasing concern to health care systems, given the large number of operations performed annually (Cheng, Pelecanos, & Sekar, 2016).
• We should aim to provide all women with evidence based care that achieves high rates of vaginal birth (Caughey, Cahill, Guise, & Rouse, 2014). All women should be involved in decision making regarding their birth options, to the extent that they wish to be.

Conclusion: There are ingrained systemic reasons why the medical model presents CS as the safe, easy option for women (Bryant, Porter, Tracy, & Sullivan, 2007). The evidence is clear – there is no population benefit for a CS rate of over 15%. Clinicians should focus on applying evidence to the care of individual women in order to achieve the best outcomes for them and for their infants.

References

Betran, A.P., Torloni, M.R., Zhang, J., Ye, J., Mikolajczyk, R., Deneux-Tharaux, C.,Gülmezoglu, A.M. (2015). What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reproductive Health, 12(1), 57–57. http://doi.org/10.1186/s12978-015-0043-6

Bozkurt, M., Yumru, A. E., & Şahin, L. (2014). Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwanese Journal of Obstetrics and Gynecology, 53(4), 452–458. http://doi.org/10.1016/j.tjog.2014.08.001

Bryant, J., Porter, M., Tracy, S., & Sullivan, E. (2007). Caesarean birth: Consumption, safety, order, and good mothering. Social Science & Medicine, 65(6), 1192–1201.

Caughey, A. B., Cahill, A. G., Guise, J.-M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179–193. http://doi.org/10.1016/j.ajog.2014.01.026

Cheng, H. C., Pelecanos, A., & Sekar, R. (2016). Review of peripartum hysterectomy rates at a tertiary Australian hospital. Australian and New Zealand Journal of Obstetrics and Gynaecology, 56(6), 614–618. http://doi.org/10.1111/ajo.12519

Dahlen, H. G., Tracy, S., Tracy, M., Bisits, A., Brown, C., & Thornton, C. (2012). Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study. BMJ Open, 2(5), e001723–e001723. http://doi.org/10.1136/bmjopen-2012-001723

Hyde, M. J., Mostyn, A., Modi, N., & Kemp, P. R. (2011). The health implications of birth by Caesarean section. Biological Reviews, 87(1), 229–243. http://doi.org/10.1111/j.1469-185X.2011.00195.x

Ogah, J., Cody, D.J. & Rogerson, L. (2011). Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: A short version Cochrane review. Neurourology and Urodynamics, 30, 284–291. doi:10.1002/nau.20980.

Parry, D. C. (2008). “We wanted a birth experience, not a medical experience”: exploring Canadian women's use of midwifery. Health Care for Women International, 29(8), 784–806. http://doi.org/10.1080/07399330802269451

Robson, J., & de Costa, M. (2017). Thirty years of the World Health Organization's target caesarean section rate: time to move on. The Medical Journal of Australia, 206(4), 181–185. http://doi.org/10.5694/mja16.00832

Toohill, J., Gamble, J., & Creedy, D. K. (2013). A critical review of vaginal birth rates after a primary Caesarean in Queensland hospitals. Australian Health Review, 37(5), 642–7. http://doi.org/10.1071/AH13044