In maternity care, we talk constantly about competence — signing people off, assessing skills, meeting standards. But in reality, competence matters, yes, but it often tells us less about safety than we like to admit. Having worked across the NHS, in independent midwifery, as a lecturer for T Level nursing students, and now supporting midwives through Mobile Midwives, I’ve seen firsthand how training, culture and system pressures shape the care families receive.
Midwives are regularly judged as individuals. But they don’t operate in a vacuum — they practise within systems that are stretched, fragmented and inconsistent. When things go wrong, the system often fades into the background, while the person standing at the bedside is the one under scrutiny.
If we want to reduce negligence claims and improve outcomes, we must look beyond individual mistakes. We need to examine how midwives are trained, how they are supported once qualified, the pressures that team working places on them, and the cultural divide between midwives and obstetricians that quietly undermines safety.
Competence in Training: Exposure ≠ Mastery
During a three year midwifery degree, many clinical skills are practiced and signed off repeatedly. Yet repetition alone doesn’t guarantee true, reflective competence. A student is often declared “competent” once a skill has been documented as observed and performed — but “see one, do one, sign off” equals exposure more than mastery.
That’s not a criticism of individual mentors or lecturers. Rather, it reveals a system under strain:
• Clinical placements are under resourced
• Students compete for the same limited learning opportunities
• Time pressure is constant
• Paperwork can sometimes take priority over in-depth practical learning
Ticking a box on a competency form often records completion, not whether the student has built the sound clinical judgement and confidence to apply a skill safely in real-world contexts.
Preceptorship is supposed to be the bridge — a protected phase where newly qualified midwives consolidate their learning and grow into autonomous practice. But far too often, the moment they graduate, the safety net feels like it’s being removed. One day they’re protected; the next, they’re expected to function like a seasoned professional.
In negligence cases, you’ll often find a well-documented trail of signatures. What’s missing is the full story behind them — the clinical reasoning, the thought process, the depth of judgement. That’s a risk many do not recognise.
Educational Variation: Not All Training Is Created Equal
There is significant variation across university programmes. While the curriculum may appear similar on paper, how and when content is delivered — the sequence, structure, and timing — can differ dramatically. In a Trust where I worked, we had students from three different universities, and I watched how their experiences diverged, not because of ability, but because of course design and timing.
Some students arrived on placement fresh from theory-heavy academic blocks; others were balancing study and clinical shifts week to week. Some got exposed to core skills early; others, not until deep into their course.
This misalignment between academic learning and clinical placement created real tension. There were occasions when students performed a skill — for example, abdominal palpation — before they had received the supporting theory. Midwives would sign off because the task had been performed, but the understanding was often shallower. When the theoretical instruction finally came, it sometimes felt disconnected from what the student had already done. What develops in such a scenario is a patchwork of experience — not a coherent, reflective competence.
Add to this the inconsistencies caused by geography and institutional reputation — differences in clinical partners, teaching staff, local practice cultures and a system under pressure to show academic progress. Many students end up spending more time chasing required sign-offs than refining their clinical judgement.
I once supported a student into a late-stage tri-partite meeting just weeks before qualification — her clinical record revealed real concern. Initially, there was resistance; some colleagues suggested I was “too harsh.” But after a three-month extension and targeted support, she herself agreed she wasn’t ready. It’s deeply concerning that it can take a near-miss at such a late stage for genuine deficits to emerge.
Compounding this, newly qualified midwives (NQMs) are now struggling to secure posts due to funding issues. Delays between qualifying and starting work can lead to de-skilling — and unfair assumptions that NQMs are “behind,” when in reality they are simply waiting for employment. From a medico-legal perspective, this creates a new category of risk: the competent-but-out-of-practice professional.
Burnout: The Hidden Systemic Threat
One of the most pervasive risks in maternity care isn’t inexperience — it’s exhaustion.
Experienced midwives are the backbone of service. They teach students; mentor newly qualified staff; manage emergencies; support families; and keep units running. But they, too, are stretched, often depleted before their shift begins. Their workload often includes:
• Supervising students and NQMs
• Covering staffing gaps
• Maintaining continuity during high-pressure shifts
• Bearing heavy emotional labour in a defensive, risk-averse culture
Burnout isn’t just “being tired.” It diminishes cognitive capacity, corrodes the ability to reflect, and reduces the bandwidth for thoughtful clinical decision making. When those who should be embedding safe practices are themselves overwhelmed, the whole system becomes fragile.
Cultural Fault Lines: Midwives vs Obstetricians
A core tension in maternity services lies in the differing worldviews of midwives and obstetricians.
Obstetricians are trained on a high-risk baseline. Their educational narrative emphasises accountability — “if something goes wrong, the buck stops here.” Their toolkit is surgical, instrument-based, and intervention-focused. Defensive practice is often not just a personal trait, but a structural necessity.
Midwives, by contrast, practise from a physiology-first, relational model. They support autonomy, nurture normal birth, and use positioning, hydration, reassurance, and biomechanics as tools to work with the body.
These two approaches don’t always align. I have seen obstetricians dismiss biomechanical or physiological strategies as “unscientific,” despite evidence of their value. At the same time, when midwives support women in making informed, non-interventive choices, it can be framed as “allowing unsafe decisions.”
This misalignment breeds miscommunication, fractured escalation pathways, and confusion — all of which show up in litigation, debriefs, and investigations, lurking in the background: confusion between teams, contradictory advice, poor communication, unclear responsibility.
Evidence vs Practice: The Gap That Harms
There is a profound gap between what evidence supports and what professionals feel they must do.
Take continuous cardiotocography (CTG) monitoring. A Cochrane review of more than 37,000 women found that although CTG was associated with fewer neonatal seizures, it made no difference to mortality or long-term neurological outcomes.1 What it did increase, however, was Caesarean and instrumental birth rates. Yet CTG remains widespread2 — not always because it is clinically essential, but often because it provides documented “proof” that can be defended when things go wrong.
Then there’s guideline lag. Trusts may rely on outdated policies that take years to update. Midwives on the floor end up navigating the tension between emerging research, institutional rules, and the individual realities of their clients. Meanwhile, junior obstetricians may follow protocols inherited from senior consultants, even when those consultants have not kept up with the latest evidence.
A stark example is induction for suspected large-for-dates babies. When I qualified, NICE guideline CG70 (2008) explicitly stated: “Induction … should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic).”3 Despite this, in practice, many women continue to report being offered induction purely on that basis.
More recently, the Big Baby Trial (2025), published in The Lancet, found that 58–60% of babies flagged as “large” on ultrasound did not actually meet macrosomia thresholds.4 Even more, early induction did not significantly reduce the risk of shoulder dystocia in an intention-to-treat analysis.
So why has this practice persisted? Part of it may be legal anxiety. For some consultants, intervening early feels safer. The system also appears to favour routine, risk-averse interventions — like early induction — even though those interventions themselves carry real risk, including postpartum haemorrhage or instrumental birth.
Harm vs Negligence: A Crucial Distinction
Negligence claims often imply a professional made a mistake. But harm isn’t always the result of poor care.
Consider a case of homebirth: a woman declined transfer but later sustained bladder damage from prolonged bladder distension. A complaint was raised about the delay in transfer. Compensation was awarded — not because the midwife was found negligent, but because an injury had occurred. The midwife judged to have met her legal and moral responsibilities in her care, in line with the Royal College of Midwives’ guidance on care outside of recommendations5, which emphasises supporting informed choices while documenting discussions of risk.
Harm in maternity can be instantaneous or accumulate over time. In this case, delay at home was a factor. But it’s also possible that actions taken later, during an instrumental delivery, made a contribution. Obstetricians are often publicly praised for “saving the day” in dramatic births, and that praise can obscure the possibility that harm occurred under their care as well.
Supporting a woman’s choice outside routine guidance can create tension: midwives and obstetricians work from different statutory duties, and these frameworks do not always align, and that divergence — structural rather than personal — can place practitioners at odds even when everyone is acting safely and professionally.
If a less experienced midwife had been involved, the same scenario might have been used as evidence of poor judgement — even if her practice was technically appropriate. It highlights how risk and accountability are often linked to experience rather than the actual quality of care.
These narratives are entrenched:
• Midwives are seen as ineffective unless women fully comply
• Obstetricians are lauded for interventions, while potential harm during their involvement receives less scrutiny
• Physiological birth is portrayed as dangerous; intervention as inherently safe
• Insurance systems frequently pay out because harm occurred, not because care was negligent
Grasping the difference between harm and negligence — and recognising the structural tensions that underpin these scenarios — is essential if we are to fairly understand and improve maternity safety.
Three Shifts That Could Improve Safety — Now
1. Reform Preceptorship & Assessment
Move away from simple “tick-box” sign-off. Use reflective journals to assess judgement, reasoning, and integration of care. Consider pairing newly qualified midwives with a senior mentor, echoing the old Supervisor of Midwives model.
2. Strengthen Interdisciplinary Understanding
Build in structured time for midwives and obstetricians to understand each other’s risk frameworks, pressures, and priorities. Elevate midwifery insight in multi-disciplinary decision-making.
3. Embed Physiological Expertise into Safety Culture
Physiology is not a “nice-to-have” — it matters for preventing emergencies. It should be equally valued as surgical or instrumental skill when evaluating what safe care means.
Conclusion
Safety in maternity care should never be framed as an “either/or” between midwives and obstetricians, normal birth and intervention, or autonomy and protection. Rather, it requires a candid understanding that individuals operate within systems that profoundly shape their decisions.
Harm often signals systemic strain — not individual failure. Cultural misunderstandings, stiff hierarchies, outdated guidance, and fractured training pathways are far more likely to produce risk than any single mistake.
To create better outcomes, fewer claims, and truly safer care, we must stop blaming individuals alone. Competence isn’t built by ticking boxes. It’s built by funding, supporting, mentoring, and valuing the full, complex role of midwives — within the system they must serve.
References:
[1] Cochrane Pregnancy and Childbirth Group. Continuous cardiotocography (CTG) for fetal assessment in labour. Cochrane Database of Systematic Reviews. 2017; CD006066.
[3] National Institute for Health and Care Excellence (NICE). Induction of Labour (CG70). 2008.
[4] Gardosi J, Ewington LJ, Booth K, et al. Induction of labour versus standard care to prevent shoulder dystocia in fetuses suspected to be large for gestational age in the UK (the Big Baby trial). Lancet. 2025;405(10491):1743–1756.
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