International Journal of Childbirth: The Official Publication of the International Confederation of MidwivesThis blog post is a re-posted article from the International Journal of Childbirth Volume 3, Number 2.  Full sample downloads of this journal are available here.

The recent publication of the Francis Inquiry Report in the United Kingdom has raised some important questions about the nature and measurement of good quality health care, and about the unspoken contract between health care providers and those receiving care (Francis Inquiry Report, 2010). These questions are relevant to health provision across the world; however it is funded and delivered.

The report was the result of an in-depth examination of one hospital that had had persistently high levels of unexpected mortality in the general hospital population over several years. At the same time, it had reported good or reasonable scores on a range of routine data collection systems that are used to judge quality in the NHS. Although concerns had been raised in the past, these were explained away as being a result of poor quality data collection. Where external concerns persisted, they were alleviated by assurances that new systems and practices had been put in place to improve the quality of care in the future. These assurances came from the hospital Trust Management and Board and were endorsed by the relevant regional body, the Strategic Health Authority.

Finally, when it became apparent that matters were not improving, and mortality rates were continuing to be far higher than would be expected, the government ordered an in-depth  investigation at all levels of the service. On this final inspection, it became clear that not only were mortality rates higher than should be expected but that the treatment of patients by staff at all levels was inhumane  at least, and potentially criminal at worst. Stories emerged of patients not given fluids, and as a consequence, having to drink from dirty vases; of them not being fed; and being left in filthy sheets. The Francis report placed blame at every single level of the organization, from the Strategic Health Authority through the Trust Board, to individual clinical staff.

The situation in this particular hospital illustrates what happens when quality is reduced to the mantra “what counts is (only) what can be counted.” This was compounded by the fact that the hospital management was cutting costs drastically as part of a drive to obtain Foundation Trust status, which required them to balance their books, at a time when they were also being asked to reduce costs because of the financial crisis. Based on the Francis report, it appears that all other issues were sacrificed to this aim, and that any staff who raised concerns risked being sacked.

Although there were no particular problems with maternity care in this case, the philosophy that reporting, measuring, and counting are a proxy for what is actually done is extremely prevalent in maternity services in the United Kingdom. Indeed, one of the phrases midwives commonly use to explain why they need to keep very extensive records is “if it isn’t written down it isn’t done.” The underlying concern seems to be not about record keeping as a way of sharing information between care providers to ensure optimum care for an individual service user but about protection from litigation. This illustrates that the original intent of keeping careful records — to deliver on the cardinal health care requirement to “first do no harm”—has been corrupted into a drive to “first protect the organization/individual professional.”

In a postmodernist  society which highly values what can be seen, verified, and calibrated, care, compassion, and empathy become relegated to luxury items— things that are only done if they can be fitted in when all the other boxes have been ticked. In the kind of environment that this creates, the few who continue to voice concerns become gradually silenced, or leave. Those who remain become complicit and, eventually, poor care is so completely normalized that the whole organization becomes functionally blind to inhumane, degrading, and life-threatening treatment.

The seminal United States Agency for International Development (USAID) landscape report on disrespect and abuse in institutional maternity care settings (Bowser & Hill, 2010) outlines a range of ways in which some of those using the maternity services are routinely deprived of basic human rights in countries across the world. There is emerging evidence from high-, low-, and middle-income countries that women who have experienced such abuses, or who hear of them, will refuse to use the maternity services, risking avoidable mortality and morbidity (Downe, Finlayson, Walsh, & Lavender, 2009; Finlayson & Downe, 2013). One powerful driver for change is to collect data on what is done, and on who is able to access services, and who is prevented from doing so. Data collection is therefore an essential tool to combat human rights abuses based on lack of services or poor quality provision. However, at the extreme, the Francis report indicates that organizations that value what can be counted over what is actually done run  the very real risk of systematically violating human  rights  in  their  turn. Maybe it is time for all of us who are concerned with maternity care including doctors, midwives, nurses, managers, funders, and policy makers to turn back to the concept of vocation as a cardinal driver for decisions about, and provision of maternity care, and to relegate record  keeping and  reporting  to  its proper place — as the servant of good-quality care, and not its master.



Bowser, D., & Hill, K. (2010). Exploring evidence for disrespect and abuse in facility-based childbirth: Report of a land- scape analysis. Bethesda, MD: USAID-TRAction Project,University Research Corporation,  LLC, and  Harvard School of Public Health USAID Review.

Downe, S., Finlayson, K., Walsh, D., & Lavender, T. (2009). ‘Weighing up and balancing out’: A meta-synthesis of barriers to antenatal care for marginalised women in high-income countries. British Journal of Obstetrics and Gynaecology, 116(4), 518–529.

Finlayson, K., & Downe, S. (2013). Why do women not use antenatal  services in low- and  middle-income  countries? A meta-synthesis of qualitative studies. PLoS Med- icine, 10(1), e1001373.

Francis Inquiry Report. (2010). The Mid Staffordshire NHS Foundation Trust Inquiry. Retrieved from