Midwifery is in crisis.Although there has been a small increase in numbers Cathy Warwick believes it simply isn't enough and that a serious shortfall remains which is putting pregnant women's lives increasingly at risk 

Professor Cathy Warwick CBE  

midsosGeneral Secretary Royal College of Midwives London In recent years we have started to see improvements in NHS maternity services in England, with almost 2,500 more midwives and over 600 more places for student midwives in the last four years. We have seen, however, that these extra midwives are largely swallowed up by the need to provide valuable one-toone care in labour. This means postnatal care remains woefully inadequate. Additionally, midwives are unable to provide the level and quality of antenatal care they need and want to provide, which means public health work - with obese or teenage mothers, for example - continues to get squeezed out.

Baby boom Nonetheless, the rises in the number of midwives has gone some of the way towards catching up with the extra demand placed on maternity services by the decade-long baby boom - with 100,000 more babies born last year, compared to 2001. Extra demand has also come from increasing complexity. Mothers are increasingly younger, or older, than before. More mothers are overweight or obese - and they all need additional care.

Election promise...The rise has however started to make up for the fact that for many years after 1997, maternity services were not a priority within the NHS: spending on maternity care as a proportion of the NHS budget fell from over three per cent in 1997 to below two per cent in 2006; and the share of the NHS workforce made up of midwives fell right throughout the Labour years. We went into the election confident that increasing the number of midwives would continue, because of a personal commitment made by David Cameron. Writing in The Sun before the election, he promised an extra 3,000 midwives because the profession was "stretched to breaking point", "overworked" and "demoralised". Whilst the shortage is still acknowledged (as recently as 9th February this year, the Prime Minister told the House of Commons: "We do need more midwives") we see no sign of this specific commitment being translated into policy. In his statement on the Spending Review, on 20th October, the Chancellor told the House: "The NHS is an intrinsic part of the fabric of our country. It is the embodiment of a fair society. This coalition Government made a commitment to protect the NHS and increase health spending every year. Today we honour that commitment in full. Total health spending will rise each year over and above inflation."  

Chronic shortage of midwives  

We welcome the desire to shield the NHS from the brunt of the cuts, but if protecting the NHS is to mean anything it must mean having enough midwives to deliver the level of maternity care women and newborns expect. Currently we are several thousand midwives short, based on calculations using established midwifery workforce planning tools. Whilst we ideally want to see that entire shortfall filled, we do acknowledge the straitened times in which the NHS is operating. We would be content with an explicit government pledge to honour the Prime Minister's promise of an extra 3,000 midwives. Although the recent NHS staff figures did show a slight increase in midwife numbers, the majority of the increase was in London, with much of the rest of England seeing very small increases, or even a fall. Also, even this modest increase is essentially the tail-end of the previous government's investment. So far we are seeing no real and concrete commitment or actions from this current government to address this issue. Aside from resources however is the question of policy.
The NHS White Paper, Equity and excellence: Liberating the NHS, promises that the Government will "extend maternity choice and help make safe informed choices throughout pregnancy and in childbirth a reality - recognising that not all choices will be appropriate or safe for all women - by developing new provider networks". It is our understanding that the previous Government's maternity care strategy, Maternity Matters, has been quietly laid to rest. So, whilst a policy commitment to choice in maternity care is very welcome, what about all the many other things that maternity care should be striving to achieve - lessening health inequalities, for example? Laissez-faire-ism will not do.

Potential levers in the bill midsos2   

We have identified some levers in the current Health and Social Care Bill. The proposed new law will allow the Secretary of State to impose "standing rules" on the NHS to require it to provide certain services, or to provide services in a certain way. We see potential here for imposing on care providers the choice promised in the White Paper.
The mandate, which the Secretary of State will have to lay before Parliament each year, will allow him or her to highlight particular improvements they want to see from the NHS; again, we see potential here for maternity care to be highlighted. The wording of the bill also means that if something is prioritised in the mandate then the monitor should adjust the tariff to support improvement, which would be helpful. Finally, NICE quality standards will drive improvements in care, and we are keen to see maternity-related practice issues prioritised. So, there is some potential in the bill for the Government to drive through improvements in care. That said, the RCM is opposed to the overall package of reforms proposed as the upheaval to the NHS is too great, particularly at such an uncertain time.

Dangers of cutting costs 

Finally, with maternity care one must always remember the price of getting it wrong or cutting corners. The price can be high, as the cost of litigation shows. Of the 100 biggest damages payouts made by the Clinical Negligence Scheme for Trusts (CNST), 79 derived from obstetric care; and of the total £3bn paid out by the CNST, almost £1.4bn is down to claims deriving from obstetrics. Cutting corners in maternity care can carry a heavy human and financial cost.


The next few years will be a rocky ride, as we need politicians to ensure that the recent improvements in NHS maternity care are maintained. If they don't then we run the very real risk of squandering what we have recently begun to achieve.