State of Maternity Services report 2015

#soms2015

State of Maternity Services Report 2015

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

2 | The Royal College of Midwives

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.

England Live births 700000 700,000 675000 675,000 650000 650,000 625000 625,000 600000 600,000 575000 575,000

Number of live births

550000 550,000

Source: the Office for National Statistics 2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

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

Births by region 135,000 135000 120,000 120000 105,000 105000 90,000 90000 75,000 75000 60,000 60000

Yorkshire & the Humber

East Midlands

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.

London

South East

+9,656 +20%

East of England

+13,896 +16%

+9,305 +15% West Midlands

+23,237 +22%

North West

+11,765 +20%

North East

+8,528 +19%

00

+8,453 +15%

15,000 15000

+2,507 +10%

30,000 30000

+10,405 +14%

45,000 45000 Number of live births, 2001 Number of live births, 2014 Source: the Office for National Statistics

South West

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 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 change in % number of live births, 2001–2014 (England and Wales) Source: the Office for National Statistics

00

-10 -10 -20 -20 -30 -30 -40 -40 under 20

20–24

25–29

30–34

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.

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

35–39

40 and over

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.

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.

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

19000

19,000

Number of full-time equivalent (FTE) midwives Source: Hansard, and Health and Social Care Information Centre

18000

18,000

17000 17,000 2001

2002

2003

2004

2005

2006

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

4 | The Royal College of Midwives

2007

2008

2009

2010

2011

2012

2013

2014

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

England Midwives: monthly figures 22500 22,500 22000 22,000 21500 21,500 21000

21,000

20500 20,500 Number of FTE midwives

20000

20,000

Source: Health and Social Care Information Centre

19500 19,500 Sept Jan May Sept Jan May Sept Jan May Sept Jan May Sept Jan May Sept Jan May 2009 2010 2010 2010 2011 2011 2011 2012 2012 2012 2013 2013 2013 2014 2014 2014 2015 2015

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

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.

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.

66 more midwives since 2005 who are aged under 50

“ We need more midwives.”

Age profile of NHS midwives in England 24 24

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

20 20

16 16

12 12 % of total midwifery workforce, 2005

8 8

% of total midwifery workforce, 2014

4 4

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

0 0 under 25

25–29

30–34

35–39

40–44

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

45–49

50–54

55–59

60–64

65 and over

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 7000 7,000 6000 6,000 5000 5,000 4000 4,000 3000 3,000 2000 2,000 Student midwives at any stage in their training Source: ministerial answers to parliamentary questions

1000 1,000 00 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 2500 2,500

2000 2,000

1500 1,500

1000 1,000

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

6 | The Royal College of Midwives

2013/14

2012/13

2011/12

2010/11

2009/10

2008/09

2007/08

2006/07

2005/06

2004/05

Academic year

2003/04

00 2002/03

Source: ministerial answers to parliamentary questions

500 500

2001/02

Student midwife places commissioned

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.

England Midwife shortage 25000 25,000

20000 20,000

2,618 shortage

3,037 shortage

4,787 shortage

4,976 shortage

5,328 shortage

5,367 shortage

6,032 shortage

5,530 shortage

5,174 shortage

4,387 shortage

4,359 shortage

3,999 shortage

5000 5,000

3,394 shortage

10000 10,000

3,316 shortage

15000 15,000

00

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.

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.

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

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.

Regional changes in number of midwives

Number of midwives Number of midwives required Source: annual NHS nonmedical 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.

7%

3000 3,000

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

2500 2,500

2000 2,000

1500 1,500

Number of FTE midwives, 2013

+3 0%

+70 +3%

+52 +2%

+22 +2%

+11 +1%

+64 +4%

+5 0%

+61 +7%

+10 +1%

+27 +3%

+28 +1%

+39 +2%

500 500

-5 0%

1000 1,000

0

0

East East of Yorkshire Wessex Thames North South North Kent, North Midlands England & the Valley West London Central Surrey East Humber London & East & Sussex London

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.

Number of FTE midwives, 2014 Source: Health and Social Care Information Centre

North West South West Midlands West

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

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,

2007

2008

2009

2010

2011

2012

2013

2014

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.

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

Age profile of mothers 80 80 60 60 40 40 20 20 00

% change in number of live births, 2001–2014 Source: General Register Office for Scotland

-20 -20 -40 -40 -60 -60 under 20

20–24

25–29

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

8 | The Royal College of Midwives

30–34

35–39

40 and over

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.

Scotland Midwives 2,450 2450

2,425 2425

2,400 2400

2,375 2375 Number of FTE midwives (bands 5–9) 2,350 2350

Source: ISD Scotland 2011

2012

2013

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

2014

2015

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

Age profile 700 700 600 600 500 500 400 400 300 300

umber of total N midwifery workforce, 2011

200 200

umber of total N midwifery workforce, 2015

100 100 0

Source: ISD Scotland

0 under 20

20–24

25–29

30–34

35–39

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.

40–44

45–49

50–54

55–59

60–64

65 and over

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 Student midwives

2% midwives

Thousands 150 150 125 125

fall in midwives under the age of 50

2001

7575 5050

2015

2525

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.

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 to women women over over 40 40 Rise in in births births to

78%

76%

increase in births to women aged 40+ in Scotland

increase in births to women aged 40+ in England

2014

15%

increase in births to women aged 40+ in Wales

2001 57%

increase in births to women aged 40+ in Northern Ireland

10 | The Royal College of Midwives

2013/14

2012/13

2011/12

2010/11

2009/10

2008/09

2007/08

2006/07

2005/06

0 2004/05

0

Academic year

England

224

100 100

2003/04

Source: ISD Scotland

2001

175 175

2002/03

Student midwife intake (conversion)

200 200

2001/02

Student midwife intake (direct)

Northern Ireland

2015

225 225

2000/01

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

342

rise in midwives over the age of 50

under age 50

250 250

Wales Live births 36000 36,000 35000 35,000 34000 34,000 33000 33,000 32000 32,000 31000 31,000

Number of live births

30000 30,000

Source: StatsWales 2001

2002

2003

2004

2005

2006

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

2007

2008

2009

2010

2011

2012

2013

2014

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% r ise in births in Wales between 2001 and 2014

Age profile of mothers 20 20

10 10

00

-10 -10

-20 -20

% change in number of live births, 2007–2012

-30 -30

Source: StatsWales under 16

16–19

20–24

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.

25–29

30–34

35–39

40 and over

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

1150

Number of FTE midwives Source: StatsWales

1150

1100

1100

2009

2010

2011

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

2012

2013

2014

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.

8% increase in midwives between 2009 and 2014

Student midwives 320 320 300 300 280 280 260 260 240 240 220 220 200 200 180 180 Number of student midwives (pre-registration) Source: Health Statistics Wales

160 160 140 140 120 120 100 100 Academic year

2008/09

2009/10

2010/11

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.

12 | The Royal College of Midwives

2011/12

2012/13

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.

Northern Ireland Live births 26000 26,000 25000 25,000

11%

24000 24,000

i ncrease in births since 2001

23000 23,000 22000 22,000

Number of live births

21000 21,000

Source: Northern Ireland Statistics and Research Agency

20000 20,000 2001

2002

2003

2004

2005

2006

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.

2007

2008

2009

2010

2011

2012

2013

2014

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

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 60 50 50 40 40 30 30 20 20 10 10 00

-10 -10

% change in number of live births, 2001–2014

-20 -20 -30 -30

Source: Northern Ireland Statistics and Research Agency

-40 -40 under 20

20–24

25–29

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.

30–34

35–39

40–44

45 and over

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

10 % of total midwifery workforce, 2001 % of total midwifery workforce, 2015 Source: Department of Health, Social Services and Public Safety.

10

5 5

0 0 under 25

25–29

30–34

35–39

40–44

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

14 | The Royal College of Midwives

45–49

50–54

55–59

60–64

65 and over

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.

Northern Ireland Student midwives 70 70 60 60 50 50 40 40 30 30

Number of student midwives, direct entry

20 20

Number of student midwives, short course

10 10

Source: Northern Ireland Statistics and Research Agency

00 2003

2004

2005

2006

2007

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

2008

2009

2010

2011

2012

(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 midwives under under the theage ageof of50 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

2015

Northern Ireland

2001

224

2001

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