“So What Happens When Lessons Aren’t Learned?”

Reflections from the Five X More Black Maternity Experiences Report Launch

“You need to be ready to fight.”

That was a haunting, repeated theme at the London launch of Five X More 's second Black Maternity Experiences Report, this morning.

And tragically, it has remained true for years. Right up to March 2025, when this latest phase of data collection ends.

I was honoured to contribute to this report as an expert panel member, supporting peer researchers Tinuke Awe and Clotilde Abe to shape the questions and ensure that Black women’s realities were heard, in full.

Harrowing...but Not New

The report captures the voices of 1,164 Black and Black mixed-heritage women across the UK who accessed maternity care while pregnant between July 2021 and March 2025.

The findings? Harrowing...but not new.

🔸 Black women are still being ignored and dismissed during maternity care

🔸 1 in 4 did not receive the pain relief they requested during labour

🔸 Nearly half weren’t even told why

🔸 Disrespect, neglect, and fear are being normalised

“So What Happens When Lessons Aren’t Learned?”

We heard devastating accounts, both in the report and in the room.

Stories of being left unmonitored in labour.

Being told “you’re not in labour” just minutes before delivery.

Being sent home without necessary checks or advice.

One mother shared how her first child died following an incident that led to a serious case review. Two years later, she returned to the same hospital to give birth again. Hopefuly of change, only to be ignored once more.

It wasn’t until the doctor who had delivered the news of her first child’s death came on shift that anyone took action. Her second baby was born via emergency section under general anaesthetic. The baby was born floppy and didn’t breathe for seven minutes.

She only found this out by reading her discharge summary at home.

And then she asked the question that echoed across the room:

“So what happens when lessons aren’t learned?”

The Cost of Not Learning

💷 According to The Guardian, the NHS now faces a £27.4 billion bill in maternity negligence claims since 2019, more than the entire newborn care budget over the same period.

But the cost isn’t just financial. It’s emotional, generational, and systemic.

That mother’s question, should echo through every hospital boardroom, every clinical governance meeting, and every policy decision. Because it’s not enough to conduct reviews and write action plans. If the same women return to the same hospitals and experience the same harm, then we’re not learning. We’re failing.

And in maternity care, those failures can be fatal.

My Experience – And the Fight That Shouldn’t Be Required

I’ve had three babies through the NHS. My eldest turns 21 this week.

Looking back, I can say my experiences were positive, but only because I was prepared. I advocated. I briefed my husband. I made sure we were ready to fight if necessary.

That should not be a requirement for survival.

And yet, 21 years later Black women still feel the need to go in ready to fight. That’s not empowerment. It’s emotional exhaustion.

Stress Has a Biological Cost

📚 The science is clear: the stress of racism, neglect, and self-advocacy has immediate, medium, and long-term effects:

🩺 Short-term: Increased risk of preterm birth, low birth weight, gestational diabetes, preeclampsia, and poor maternal mental health

🧠 Medium-term: Ongoing postpartum depression, disrupted bonding, poor infant development

⏳ Long-term: Chronic illness, immune dysfunction, and accelerated biological ageing, known as weathering

🧬 Intergenerational: Epigenetic changes that affect the health outcomes of children and future generations

This isn’t just about individual health. It’s the biological embodiment of systemic failure.

What Needs to Happen

As lived experience speaker Sarah Josiah reminded us:

“We need to move away from targets, and actually see the person in front of us...and be culturally aware.”

This report is not just for maternity services.

It’s for policymakers, commissioners, public health teams, clinicians, educators, and anyone who wants to be part of a system that heals, not harms.

What You Can Do

✅ Read the report

✅ Share it with your team, network, or leadership

✅ Reflect on the stories and the systemic failures they reveal

Even if it feels uncomfortable. Even if you’re tempted to say “That’s not a problem here.” Because the truth is, this isn’t just happening elsewhere. And we don’t fix what we don’t face.

✅ Act as someone who listens, learns, and leads with humanity

📖 Download the full report here:

👉 Five X More Black Maternity Experiences Survey 2025

Because when we improve care for Black women, we raise the standard for everyone.

Thank you to Five X More for your tireless work, and to every mother who bravely shared her story in the hope that others might not have to live through the same pain.

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