State of Maternity Services Report 2015 · century. The fall in 2013 has been largely halted. A...

State of Maternity Services Report 2015

#soms2015

Executive summary

Another year passes and NHS maternity services in England remain thousands of midwives short. Our latest calculation is that the country needs 2,600 more midwives to be able to cope with the number of births the country is experiencing.

If a shortage did not exist, midwives would be able to spend more time with women antenatally helping them quit smoking, for example, and postnatally to help them initiate and sustain breastfeeding – meaning healthier mothers and infants – and spot signs of mental health problems. With maternity services under intense stress and strain, these things are inevitably pushed to the sidelines. When there are not enough midwives it is the quality of the service that women receive that suffers.

With NICE having now published safe staffing guidelines for maternity, trusts in England that provide maternity care should know how many midwives they need to employ. Any failure to employ enough midwives and any consequences that flow from that failure must rest with the senior managers who continue to choose not to staff their service safely.

It is not just the current shortage of midwives in England that concerns us however. In preparing this year’s State of Maternity Services Report, we

training numbers by either the UK Government or the devolved administrations. Indeed, if possible we should see numbers rise. The administrations should maintain the financial support given to student midwives too, to ensure as many as possible stick with their studies and are not forced to quit through strained personal circumstances.

It continues to be important to highlight that we can never know what will happen to birth figures in the coming years. It appeared for a short time that numbers were on the slide. Birth figures from 2013 had suggested the baby boom might turn into a slump. The number of births was down in each part of the United Kingdom. In England, the fall was almost 30,000 compared to the year before. In Scotland, the drop was a little over 2,000. In Wales, by almost 1,500. In Northern Ireland, by just under 1,000.

Last year however the fall was much shallower in England, at just 3,000, and 200 in Wales. In Scotland and Northern Ireland there were, in fact, rises in the number of babies compared to 2013, of 700 and 100 respectively. Overall the fall in the number of babies born in the UK as a whole in 2014 was just 0.3 per cent down on 2013, having fallen by more than four per cent the year before. We just don’t know if numbers will start rising again this year.

We have long known that the midwifery profession is ageing, but the facts unearthed in the creation of this year’s State of Maternity Services Report lay bare the scale of the problem. We’ve found a midwifery retirement time bomb – and it’s ticking. Thankfully we still have time to defuse it, but we need to start before it’s too late.

“ When there are not enough midwives it is the quality of the service that women receive that suffers.”

unearthed a fact that makes us fear that the situation may be about to get much worse, and hit other parts of the UK too.

Between 2005 and 2014 the number of midwives working in England’s NHS rose. But if we look at the age profile of midwives now and then we see that 98 per cent of the increase occurred amongst midwives aged 50 or older. The number of midwives falling into this category rose by 3,106 between 2005 and 2014, whilst the number aged below 50 rose by just 66.

Many of these older midwives are very experienced, of course, and they are able to mentor newer midwives too. They are giving valuable service to the NHS. But with around a third of midwives in England (31 per cent) aged 50 or older, we must ensure that they are replaced in good time before they retire. If we wait, there will not be enough time for newly-qualified midwives to gain the experience and confidence they need before many of their more senior, more experienced colleagues leave the service.

This is not just a problem for England. In Scotland, figures are collected for midwifery staff (midwives and maternity care assistants), and these show that the percentage of staff aged 50 or older rose from a third (32 per cent) in 2011 to two-fifths (42 per cent) this year.

In Northern Ireland, the difference is even more pronounced. Between 2001 and 2015, the number of midwives aged under 50 actually fell by 224, whilst those aged 50 or over rose by 342. In 2001, 83 per cent of midwives were in the younger age category; this year, that was down to 59 per cent. We do not have numbers for Wales.

This retirement time bomb reinforces the argument that at the very least we must not see any cuts to midwifery

2 | The Royal College of Midwives

The number of babies born in 2014 was almost 100,000 higher than it was in 2001. Maternity services are still having to cope with a substantially greater level of activity than at the turn of the century. The fall in 2013 has been largely halted. A fall of 4.3 per cent has been followed by a fall of 0.5 per cent.

And whilst the number of births is well up in every region, some have seen bigger rises than others. In the North East, for example, births were up 10 per cent between 2001 and 2014; the jump was at least twice as great however in eastern England (20 per cent), the South West (also 20 per cent) and London (22 per cent).

0

15000

30000

45000

60000

75000

90000

105000

120000

135000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2012 2013 201420112010

NorthEast

NorthWest

Yorkshire & the

Humber

EastMidlands

WestMidlands

East of England

London South East

South West

Number of live births

Source: the Office for National Statistics

Number of live births, 2001

Number of live births, 2014


Live births

+2,

507

+10%

+10

,405

+14

%

+8,

453

+15

%

+8,

528

+19

%

+9,

305

+15

%

+11

,765

+20

%

+23

,237

+22

%

+13

,896

+16

%

+9,

656

+20

%

England

700,000

675,000

650,000

625,000

600,000

575,000

550,000

135,000

120,000

105,000

90,000

75,000

60,000

45,000

30,000

15,000

0

Births by region

550000

575000

600000

625000

650000

675000

700000

97,752more babies born in England in 2014, compared to 2001

State of Maternity Services | 3

There have been two marked changes to the age profile of mothers since the start of the baby boom in 2001: the dramatic fall in the number of babies born to teenagers; and the rise in the number of births to older women.

Between 2001 and 2014 births to woman and girls aged under 20 fell by 41 per cent, from over 44,000 to below 26,000; births to women aged between 20 and 24 remained stable (up three per cent).

At the same time, births to women in their early thirties topped 200,000 and for women in their late thirties the number rose 33 per cent to top 100,000.

It was up three-quarters (78 per cent) for women aged 40 and over.

Taken as a whole, women who give birth later in life will on average need more care from the NHS. That will not be the case for every woman in that category, but it will be true on average. They are perfectly entitled to that care, of course, and should receive it, but the added complexity and cost means that more needs to be invested in maternity care to ensure they get it.

The effect of this change in the age profile of mothers does reinforce the need for more midwives.

Age profile of mothers

3,106more midwives since 2005 who are aged 50 or older

-40

-30

-20

-10

0

10

20

30

40

50

60

70

80

% change in number of live births, 2001–2014 (England and Wales)


80

70

60

50

40

30

20

10

0

-20

-30

-40

-10

20–24 25–29 30–34 35–39 40 and overunder 20

17000

18000

19000

20000

21000

22000

Midwives

Number of full-time equivalent (FTE) midwives

Source: Hansard, and Health and Social Care Information Centre

2001 2002 2003 2004 2005 2006 2007 2008 2009 20142013201220112010

The number of midwives continues to rise, which is welcome. The rise has not been fast enough however. The shortage of midwives has been

known about and discussed for years, but it is still with us. The rise must be maintained if we are to eliminate the shortage.

19,000

17,000

18,000

20,000

22,000

21,000

England


% of total midwifery workforce, 2005


Source: Hansard, and annual NHS non-medical workforce censuses

The biggest jump in midwife numbers comes every year between September and November, as newly-qualified midwives are taken on by trusts.

In 2010 this two-month period saw a rise of 302 midwives, followed by 509 in 2011, 578 in 2012, 680 in 2013, and by 693 in 2014. This number has therefore steadily risen in recent years.

Recent years have seen the number of places for new student midwives maintained at a good level. This needs to continue if we are to see a sustained influx of new midwives from training. 66

more midwives since 2005 who are aged under 50

19500

20000

20500

21000

21500

22000

22500

Midwives: monthly figures

Sept 2009

Sept 2014

Sept 2013

Sept 2012

Sept 2011

Jan 2010

May 2010

May 2015

May 2014

May 2013

May2012

May 2011

Jan 2012

Jan 2015

Jan 2014

Jan 2011

Jan 2013

21,000

19,500

20,000

20,500

22,000

21,500

22,500

Age profile of NHS midwives in England

It is in the age profile of the midwifery profession that the biggest problem lies.

Between 2005 and 2014 the number of midwives working in the NHS in England rose. Whilst welcome, this was not enough. It did

0

4

8

12

16

20

24

under 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 and over

24

20

16

12

8

4

0

help push down the shortage, but looked at in more detail this increase is shown to be a short-term sticking plaster. Almost all (98 per cent) of the increase between 2005 and 2014 has been in midwives aged 50 or older. Only 2 per cent (66 midwives out of 3,172) were younger than 50.

Sept 2010

England

Number of FTE midwives

Source: Health and Social Care Information Centre

“ We need more midwives.”

Rt. Hon. Jeremy Hunt MP, Secretary of State for Health, 13th October 2015


The number of places for new student midwives reached around 2,500 in 2009/10 and has remained there. We welcome the fact that this number has not

been cut. Given the age profile set out earlier, there is a clear need to maintain training numbers. Indeed, we would argue there is a case to scale it up.

0

500

1000

1500

2000

2500

0

1000

2000

3000

4000

5000

6000

7000

New student midwives

All student midwives

2003

/04

2002

/03

2001

/02

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09

2009/10 2010/11 2011/12 2012/13 2013/14

2009

/10

2010

/11

2012

/13

2013

/14

2011

/12

Student midwife places commissioned

Source: ministerial answers to parliamentary questions

Student midwives at any stage in their training

Source: ministerial answers to parliamentary questions

Academic year

Academic year

2,500

7,000

2,000

2,000

1,500

3,000

4,000

5,000

1,000

1,000

500

6,000

0

0

England

“ We do need to expand maternity provision.”

Rt. Hon. Jeremy Hunt MP, Secretary of State for Health, 13th October 2015


Number of FTE midwives, 2013

Number of FTE midwives, 2014

Source: Health and Social Care Information Centre

Number of midwives

Number of midwives required

Source: annual NHS non-medical workforce censuses & RCM calculations

Note: All figures used here and throughout this report are an RCM estimate based on the minimum number of midwives needed to provide one-to-one care in labour for women, taking account of place of birth, antenatal and postnatal care, annual and sick leave, training, managerial and specialist roles and other factors. The estimates do not take into account the increasing complexity of birth.

0

500

1000

1500

2000

2500

3000

Wessex Thames Valley

NorthWest

London

Yorkshire & the

Humber

EastMidlands

East of England

North Central & East

London

SouthLondon

WestMidlands

NorthWest

NorthEast

Kent, Surrey

& Sussex

South West

-5

0%

+39

+2%

+28

+1%

+27

+3%

+10

+1%

+61

+7%

+5

0%

+11

+1%

+22

+2%

+52

+2%

+70

+3%

+3

0%

+64

+4%

There has been a steady rise in the number of midwives working in the NHS in England. The effort to increase this number has been welcome, but more midwives are needed.

A service that is thousands of midwives short operates under intense stress and strain, and cannot possibly provide the quality of care that women deserve.

The most recent figures show that some areas are growing their midwifery workforce faster than others, even ones next to each other – NW London increased its number of midwives by seven per cent between 2013 and 2014, whilst South London’s workforce was virtually unchanged.

3,000

2,500

2,000

1,500

1,000

500

0

Regional changes in number of midwives

Midwife shortage

We estimate that the NHS in England is short of around 2,600 midwives. This is down on recent years, and much reduced from the high of around 6,000 in 2008.

We doubt however that this reduction is felt by midwives on the frontline of providing care. Does it feel different to be slightly less massively understaffed? We suspect not. Added to that there

must surely be a cumulative effect from coping year after year after year with the stresses and strains caused by such a colossal shortfall in midwife numbers.

Our only hope is that the gradual reduction in the shortage spurs decision-makers on to eliminate it for good. It is possible; Scotland, Wales and Northern Ireland have managed it for years.

0

5000

10000

15000

20000

25000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2012 2013 201420112010

25,000

20,000

15,000

10,000

5,000

0

3,31

6 sh

ort

age

4,35

9 sh

ort

age

5,53

0 sh

ort

age

5,32

8 sh

ort

age

3,39

4 sh

ort

age

4,38

7 sh

ort

age

6,03

2 sh

ort

age

4,97

6 sh

ort

age

3,03

7 sh

ort

age

2,61

8 sh

ort

age

3,99

9 sh

ort

age

5,17

4 sh

ort

age

5,36

7 sh

ort

age

4,78

7 sh

ort

age

England

7%rise in the number of midwives in North West London between 2013 and 2014


2012

% change in number of live births, 2001–2014

Source: General Register Office for Scotland


Source: General Register Office for Scotland


-60

-40

-20

0

20

40

60

80

The number of births in Scotland to women and children aged under 20 fell 45 per cent between 2001 and 2014, from around 4,500 to around 2,500. Meantime the number of babies born to

women aged in their late thirties rose by 21 per cent and for women aged 40 or over the rise was three-quarters (76 per cent), or by almost 1,000.

20–24 25–29 30–34 35–39under 20 40 and over

80

60

40

20

0

-20

-40

-60

Scotland

The number of babies born in Scotland has not followed quite the same path as in England. The number rose from 2002 until 2008, rising 17 per cent to top 60,000. It then remained around that level, dropping back below 60,000,

between 2009 and 2012. In 2013 we saw a small but noticeable (three per cent) drop, to 56,000. Last year however the number rose again, up a little over 1 per cent, to 56,725.

2002 2003 2004 2005 2006 2007 2008 2009 2014201320112010

Live births

50000

52000

54000

56000

58000

6000060,000

58,000

56,000

54,000

52,000

50,000

2001

711more births in Scotland last year, compared to the year before


Number of FTE midwives (bands 5–9)

Source: ISD Scotland2350

2375

2400

2425

2450

Midwives

2011 20152013 20142012

2,400

2,425

2,450

The number of midwives working in the NHS in Scotland has been fairly stable – a little either side of 2,400 – for a few years now. We do not believe

that, at the national level, there is currently a shortage of midwives in Scotland.

2,350

2,375

Scotland

Age profile

In Scotland, between 2011 and 2015, the number of staff (midwives and maternity care assistants) aged under 50 fell by 207 whilst the number aged 50 or over rose by 303. Overall, the percentage aged 50 or older rose from a third (32 per cent) to two-fifths (42 per cent) during this period.

0

100

200

300

400

500

600

700

Number of total midwifery workforce, 2011

Number of total midwifery workforce, 2015

Source: ISD Scotland

under 20 25–2920–24 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 and over

700

600

500

400

300

200

100

0

As in England, the age profile is increasingly skewed towards older age categories. There are advantages to this at the present time, with more midwives in post who are typically more experienced, but there is a bigger disadvantage – namely that these midwives must be replaced, and quickly, if Scotland is not to face a serious shortage as they retire in the near future.


Scotland

Student midwife intake (direct)

Student midwife intake (conversion)

Source: ISD Scotland

We urge the Scottish Government to look at the current number of student midwife places it is commissioning, with particular regard to the need to correct the imbalance in the age profile. More, younger midwives are needed if we are to avoid a serious problem in the near future caused by the retirement of so many midwives.

0

25

50

75

100

125

150

175

200

225

250

Student midwives

2001

/02

2000

/01

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2011

/12

2012

/13

2013

/14

2010

/11

2009

/10

2008

/09Academic

year

250

200

225

175

150

100

125

75

25

50

0

It might feel difficult to justify when there is no current shortage of midwives in Scotland, but if nothing is done to address the age profile issue there could be serious consequences for the quality and even the safety of Scottish maternity services.

Rise in births to women over 40

Not enough midwives under the age of 50

England

NorthernIreland

224 fall in midwives under the age of 50

342 rise in midwives over the age of 50

2% midwives under age 50


2001

78%increase in births to women aged 40+in England

15%increase in births to women aged 40+ in Wales

76% increase in births to women aged 40+ in Scotland

57% increase in births to women aged 40+ in Northern Ireland

2001

2015

2015

2001

Thousandsmore midwives since 2005, but only 66 were under the age of 50

2014


Wales

Just like Scotland, Wales saw a rise in the number of births between 2002 and 2008; in Wales the increase was 18 per cent, or about 5,500. Also like Scotland, Wales then witnessed a small tailing off

of the number, before falling noticeably in 2013. And in the most recent year for which we have figures, 2014, the number pretty much stopped falling, down just 0.6 per cent on the previous year.

2001 2002 2003 2004 2005 2006 2007 2008 2009 20142011 2012 20132010


Source: StatsWales

Live births

30000

31000

32000

33000

34000

35000

36000


Source: StatsWales

36,000

34,000

35,000

33,000

32,000

30,000

31,000


-30

-20

-10

0

10

20

Like elsewhere in the UK, Wales has seen a fall in the number of births to women and girls aged under 20 and a rise in the number of babies born to older women. In Wales however both changes have been less pronounced than elsewhere.

Between 2007 and 2012, the fall in births to those aged under 16 was 27 per cent, and for those aged 16 to 19 the figure was 26 per cent.

During the same period, births to women in their early thirties was up, but by just 11 per cent, but births to women in their late thirties actually fell, by 10 per cent. For the oldest age group, women aged 40 or above, the number was up, but by 15 per cent.

Overall the changes in Wales – in midwife and birth numbers – were less pronounced than elsewhere in the UK.

16–19 20–24 25–29 35–3930–34 40 and overunder 16

20

10

-20

-10

0

-30

10% rise in births in

Wales between 2001 and 2014


There were more midwives working in the NHS in Wales last year than there have been since at least 2009. The increase during that time was 99

midwives, or around eight per cent. This has outpaced the changed in the number of births, helping to reduce the ratio of births per midwife.

1100

1150

1200

1250

1300

1350

2009 2010 2011 2012 20142013


Source: StatsWales

1350

1300

1250

1200

1150

1100

Midwives

The number of places for student midwives in Wales rose from 200 in 2008/09 to stand at around 300 during the period 2011/12–2013/14.

We do not have age profile information for midwives in Wales but have no reason to believe that the problem every other part of the UK has – a profession where an increasing proportion is nearing retirement age – may not also apply to Wales.

100

120

140

160

180

200

220

240

260

280

300

320

Student midwives

2008/09 2009/10 2012/13 2013/142010/11Academic year

260

320

220

280

240

300

200

180

140

160

120

100

Number of student midwives (pre-registration)

Source: Health Statistics Wales

2011/12

Wales

8%increase in midwives between 2009 and 2014


The number of babies born in Northern Ireland has also been very stable in recent years, varying between around 24,500 to 25,500 since 2007.

As happened in Scotland, last year saw a rise in the number, compared to 2013.


Source: Northern Ireland Statistics and Research Agency

Note: As with the rest of the report, this includes only the number of live births to usually resident mothers. However, in large part due to Northern Ireland’s shared border with the Republic of Ireland, a significant number of non-residents also give birth in Northern Ireland, increasing the pressure on maternity services.

Live births




As elsewhere in the UK, Northern Ireland has also seen a dramatic fall in the number of babies born to women and girls aged below 20 – and for Northern Ireland also for women in their early twenties.

Births to women in their thirties was up by 22 per cent, or almost 2,200. And the share of all births that were to women in their early forties doubled.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2014201320122010

20000

21000

22000

23000

24000

25000

2600026,000

24,000

25,000

23,000

22,000

20,000

21,000

-40

-30

-20

-10

0

10

20

30

40

50

60

20–24 25–29 30–34 40–4435–39 45 and overunder 20

60

30

40

20

10

-40

-30

-10

0

2011

-20

50

Northern Ireland

11% increase in births

since 2001


Age profile of midwives

We do not believe that there is a shortage of midwives in the NHS in Northern Ireland. We do however have concerns about the age profile of the profession. As happened in Scotland, the number of midwives aged under 50 actually fell in recent years, by 224 between 2001 and 2015, whilst the number aged 50 or older rose

during the same period, by 342. This makes the overall situation look quite healthy, with a growing workforce, but it is a workforce where a sizeable chunk are not too far off retirement.

This needs to be addressed as a matter of urgency.

0

5

10

15

20

25

under 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 and over

25

15

20

10

5

0


Source: Department of Health, Social Services and Public Safety.



Source: Department of Health, Social Services and Public Safety.

900

925

950

975

1000

1025

1050

1075

1100

2001 2002 2003 2004 2005 2006 2007 2008 2009 2011 20152014201320122010

1,100

1,075

1,050

1,025

975

950

900

925

Midwives

1,000

Northern Ireland

224fewer midwives in Northern Ireland aged under 50 in 2015 than there were in 2001


Student midwife numbers in Northern Ireland have been fairly stable in recent years, first increasing to 65 (2009–2011) before nudging down a little to 60

(2012). An urgent analysis needs to be conducted into whether this will produce the new midwives needed to deal with the changing age profile of the profession.

0

10

20

30

40

50

60

70

2003 2004 2005 2006 2007 2008 2009 2011 20122010

70

60

50

40

30

20

10

0

Student midwives

Number of student midwives, direct entry

Number of student midwives, short course


Northern Ireland

Not enough midwives under the age of 50Not enough midwives under the age of 50

England

NorthernIreland

224 fall in midwives under the age of 50

342 rise in midwives over the age of 50

2% midwives under age 50


2001

78%increase in births to women aged 40+in England

15%increase in births to women aged 40+ in Wales

76% increase in births to women aged 40+ in Scotland

57% increase in births to women aged 40+ in Northern Ireland

2001

2015

2015

2001

Thousandsmore midwives since 2005, but only 66 were under the age of 50

2014


The Royal College of MidwivesHeadquarters15 Mansfield StreetLondon W1G 9NH020 7312 [email protected]

Report compiled by Stuart Bonar

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