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But sometimes, too, it is down to the health service failing to respond effectively to a woman who is waving her arms above her head, saying: "Help!
Nearly 20 years on from those findings, the police watchdog report on the issue tells a story of some success, but also of a stretched police service failing to follow policies formulated to tackle the issue.
Really it's another example of the the grey little men of the civil service failing to think outside the box.
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So why are maternity services failing women so badly in this area of care?
Among their conclusions, Bichard's team found different services failing to co-ordinate and service users receiving the same service several times over from different government departments.
In 2010 I took out a contract with Orange for an iPad and cancelled it the same day due to their customer services failing to get it working.
"It is right that robust plans are put in place to minimise the risk of services failing and that there is scrutiny of their business models.
An interactive "dementia atlas", published online on Tuesday by the Department of Health, shows that standards of care vary widely in different areas, with services failing to reach almost half the patients for check-ups even once a year in one area.
It was about alienated voters, fractured communities, under-resourced public services, failing schools and hospitals, low wages and zero-hours contracts – and the seething, hitherto repressed anger of so many people who feel they have been left behind.
Bed-blocking at two Gloucestershire hospitals is being blamed on care services failing to get care plans into place quickly enough for patients.
"It is not fair to the children we are working to protect that Ofsted inspections only focus on council children's services, failing to properly assess the essential work done by other organisations".
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Since I tried Ludwig back in 2017, I have been constantly using it in both editing and translation. Ever since, I suggest it to my translators at ProSciEditing.

Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com