State of Maternity Services Report 2015

State of Maternity
Services Report 2015
#soms2015

Executive summary
“When there are
not enough
midwives it is
the quality of the
service that
women receive
that suffers.”
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
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
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.
2 | The Royal College of Midwives

England
Live births
700000 700,000
675000 675,000
650000 650,000
625000 625,000
600000 600,000
575000 575,000
550000 550,000
Number of
live births
Source: the Office for
National Statistics
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Births by region
97,752
more babies born in
England in 2014,
compared to 2001
135000 135,000
120000 120,000
105000 105,000
90,000 90000
75,000 75000
60,000 60000
45,000 45000
30,000 30000
15,000 15000
0
+2,507 +10%
North
East
+10,405 +14%
North
West
+8,453 +15%
Yorkshire
& the
Humber
+8,528 +19%
East
Midlands
+9,305 +15%
West
Midlands
+11,765 +20%
East of
England
+23,237 +22%
London
+13,896 +16%
South
East
+9,656 +20%
South
West
Number of live
births, 2001
Number of live
births, 2014
Source: the Office for
National Statistics
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).
State of Maternity Services | 3

England
Age profile of mothers
% change in
number of live
births, 2001–2014
(England and Wales)
Source: the Office for
National Statistics
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0
-10 -10
-20 -20
-30 -30
-40 -40
under 20
20–24 25–29 30–34 35–39 40 and over
3,106
more midwives
since 2005 who are
aged 50 or older
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.
Midwives
22000 22,000
21000
21,000
20000
20,000
Number of
full-time equivalent
(FTE) midwives
Source: Hansard, and
Health and Social Care
Information Centre
19000
19,000
18000
18,000
17000 17,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
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.
4 | The Royal College of Midwives

England
Midwives: monthly figures
22500 22,500
22000 22,000
21500 21,500
21000
21,000
20500 20,500
20000
20,000
19500 19,500
Number of FTE
midwives
Source: Health
and Social Care
Information Centre
Sept
2009
Jan
2010
May
2010
Sept
2010
Jan
2011
May
2011
Sept
2011
Jan
2012
May
2012
Sept
2012
Jan
2013
May
2013
Sept
2013
Jan
2014
May
2014
Sept
2014
Jan
2015
May
2015
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
Age profile of NHS midwives in England
24
24
20
20
16
16
12
12
8
8
4
4
0
0
“We need
more
midwives.”
Rt. Hon. Jeremy Hunt
MP, Secretary
of State for Health,
13th October 2015
% of total midwifery
workforce, 2005
% of total midwifery
workforce, 2014
Source: Hansard, and
annual NHS non-medical
workforce censuses
under 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 and over
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
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.
State of Maternity Services | 5

England
All student midwives
7,000 7000
6,000 6000
5,000 5000
4,000 4000
3,000 3000
Student midwives at any
stage in their training
Source: ministerial answers
to parliamentary questions
2,000 2000
1,000 1000
0
Academic
year
2009/10 2010/11 2011/12 2012/13 2013/14
“We do need
to expand
maternity
provision.”
Rt. Hon. Jeremy Hunt
MP, Secretary of
State for Health,
13th October 2015
New student midwives
2,500 2500
2,000 2000
1,500 1500
1,000 1000
Student midwife places
commissioned
Source: ministerial answers
to parliamentary questions
500
0
Academic
year
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
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.
6 | The Royal College of Midwives

England
Midwife shortage
25000 25,000
20000 20,000
15000 15,000
10000 10,000
5000 5,000
0
3,316 shortage
3,394 shortage
3,999 shortage
4,359 shortage
4,387 shortage
5,174 shortage
5,530 shortage
6,032 shortage
5,367 shortage
5,328 shortage
4,976 shortage
4,787 shortage
3,037 shortage
2,618 shortage
Number of
midwives
Number of
midwives required
Source: annual NHS nonmedical
workforce censuses
& RCM calculations
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
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.
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.
Regional changes in number of midwives
3,000 3000
2,500 2500
2,000 2000
7%
rise in the number
of midwives in
North West London
between 2013
and 2014
1,500 1500
1,000 1000
Number of FTE
midwives, 2013
500
500
0
0
-5 0%
East
Midlands
+39 +2%
East of
England
+28 +1%
Yorkshire
& the
Humber
+27 +3%
Wessex
+10 +1%
Thames
Valley
+61 +7%
North
West
London
+5 0%
South
London
+64 +4%
North
Central
& East
London
+11 +1%
Kent,
Surrey
& Sussex
+22 +2%
North
East
+52 +2%
North
West
+70 +3%
West
Midlands
+3 0%
South
West
Number of FTE
midwives, 2014
Source: Health and Social
Care Information Centre
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.
State of Maternity Services | 7

Scotland
Live births
60000
60,000
58000
58,000
56000
56,000
54000
54,000
Number of live
births
Source: General Register
Office for Scotland
52000
52,000
50000
50,000
2001
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
711
more births in
Scotland last
year, compared
to the year before
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,
Age profile of mothers
80
60
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.
40
20
0
% change in
number of live
births, 2001–2014
Source: General Register
Office for Scotland
-20
-40
-60
under 20
20–24 25–29 30–34 35–39
40 and over
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.
8 | The Royal College of Midwives

Scotland
Midwives
2450 2,450
2425 2,425
2400 2,400
2375 2,375
2350 2,350
2011 2012
2013 2014
2015
Number of FTE
midwives (bands 5–9)
Source: ISD Scotland
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.
700 700
600 600
500 500
400 400
Age profile
300 300
200 200
100 100
0
0
Number of total
midwifery
workforce, 2011
Number of total
midwifery
workforce, 2015
Source: ISD Scotland
under 20 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 and over
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.
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.
State of Maternity Services | 9

Not Scotland enough midwives under the age of 50
250 250
Thousands
225 225
more midwives
since 2005, but
only 66 were
under the age
of 50
Student midwife
intake (direct)
Student midwife
intake (conversion)
Source: ISD Scotland
Student midwives
200 200
175 175
150 150
125 125
100 100
75 75
50 50
25 25
0 0
2% midwives
under age 50
342 rise in
midwives over
the age of 50
2001
2001
2015
Northern
Ireland
224 fall in midwives
under the age of 50
2015
England
Academic
year
2000/01
2001/02
2002/03
2003/04
2004/05
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.
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
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
78%
increase
in births
to women
aged 40+
in England
76%
increase in births
to women aged
40+ in Scotland
2001
2014
15%
increase in births
to women aged
40+ in Wales
57%
increase in births to women
aged 40+ in Northern Ireland
10 | The Royal College of Midwives

Wales
Live births
36,000
36000
35,000
35000
34,000
34000
33,000
33000
32,000
32000
31,000 31000
30,000 30000
Number of live
births
Source: StatsWales
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
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
Age profile of mothers
20
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.
10%
rise in births in
Wales between
2001 and 2014
10
0
-10
-20
% change in
number of live
births, 2007–2012
-30
under 16
16–19 20–24 25–29 30–34 35–39 40 and over
Source: StatsWales
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.
State of Maternity Services | 11

Wales
Midwives
1350 1350
1300
1300
1250
1250
1200
1200
Number of FTE
midwives
Source: StatsWales
1150
1150
1100
1100
2009 2010 2011 2012 2013
2014
8%
increase in
midwives between
2009 and 2014
Number of
student midwives
(pre-registration)
Source: Health
Statistics Wales
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
Student midwives
320
300
280
260
240
220
200
180
160
140
120
100
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.
Academic
year
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14
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.
12 | The Royal College of Midwives

Northern Ireland
Live births
26000 26,000
25,000 25000
24,000 24000
23,000 23000
22,000 22000
21,000 21000
20,000 20000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 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.
11%
increase in births
since 2001
Number of
live births
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.
Age profile of mothers
60
50
40
30
20
10
0
-10
-20
-30
-40
% change in
number of live
births, 2001–2014
Source: Northern
Ireland Statistics and
Research Agency
under 20
20–24 25–29 30–34 35–39 40–44 45 and over
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.
State of Maternity Services | 13

Northern Ireland
Midwives
1100
1,100
1075
1,075
1050
1,050
1025
1,025
1000
1,000
975
975
Number of
FTE midwives
Source: Department of
Health, Social Services
and Public Safety.
950
950
925
925
900
900
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
224
fewer midwives
in Northern Ireland
aged under 50
in 2015 than there
were in 2001
Age profile of midwives
25
25
20
20
15
15
% of total midwifery
workforce, 2001
% of total midwifery
workforce, 2015
Source: Department of
Health, Social Services
and Public Safety.
10
10
5
5
0
0
under 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65 and over
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.
14 | The Royal College of Midwives

Northern Ireland
Student midwives
70
60
50
40
30
20
10
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Number of student
midwives, direct entry
Number of student
midwives, short course
Source: Northern
Ireland Statistics and
Research Agency
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.
Not enough midwives under the age of of 50
Thousands
more midwives
since 2005, but
only 66 were
under the age
of 50
2% midwives
under age 50
342 rise in
midwives over
the age of 50
2001
2001
2015
Northern
Ireland
224 fall in midwives
under the age of 50
2015
England
State of Maternity Services | 15

The Royal College of Midwives
Headquarters
15 Mansfield Street
London W1G 9NH
020 7312 3535
info@rcm.org.uk
www.rcm.org.uk
Report compiled by Stuart Bonar