State of Maternity Services Report #soms2015

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1 State of Maternity Services Report 215 #soms215

2 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 2,6 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 25 and 214 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 5 or older. The number of midwives falling into this category rose by 3,16 between 25 and 214, whilst the number aged below 5 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 5 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 5 or older rose from a third (32 per cent) in 211 to two-fifths (42 per cent) this year. In Northern Ireland, the difference is even more pronounced. Between 21 and 215, the number of midwives aged under 5 actually fell by 224, whilst those aged 5 or over rose by 342. In 21, 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 213 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 3, compared to the year before. In Scotland, the drop was a little over 2,. In Wales, by almost 1,5. In Northern Ireland, by just under 1,. Last year however the fall was much shallower in England, at just 3,, and 2 in Wales. In Scotland and Northern Ireland there were, in fact, rises in the number of babies compared to 213, of 7 and 1 respectively. Overall the fall in the number of babies born in the UK as a whole in 214 was just.3 per cent down on 213, 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

3 England Live births 7, 675, 65, 625, 6, 575, 55, Number of live births Source: the Office for National Statistics Births by region 97,752 more babies born in England in 214, compared to , 12, 15, 9, 75, 6, 45, 3, 15, +2,57 +1% North East +1,45 +14% North West +8, % Yorkshire & the Humber +8, % East Midlands +9,35 +15% West Midlands +11,765 +2% East of England +23, % London +13, % South East +9,656 +2% South West Number of live births, 21 Number of live births, 214 Source: the Office for National Statistics The number of babies born in 214 was almost 1, higher than it was in 21. Maternity services are still having to cope with a substantially greater level of activity than at the turn of the century. The fall in 213 has been largely halted. A fall of 4.3 per cent has been followed by a fall of.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 1 per cent between 21 and 214; the jump was at least twice as great however in eastern England (2 per cent), the South West (also 2 per cent) and London (22 per cent). State of Maternity Services 3

4 England Age profile of mothers % change in number of live births, (England and Wales) Source: the Office for National Statistics under and over 3,16 more midwives since 25 who are aged 5 or older There have been two marked changes to the age profile of mothers since the start of the baby boom in 21: the dramatic fall in the number of babies born to teenagers; and the rise in the number of births to older women. Between 21 and 214 births to woman and girls aged under 2 fell by 41 per cent, from over 44, to below 26,; births to women aged between 2 and 24 remained stable (up three per cent). At the same time, births to women in their early thirties topped 2, and for women in their late thirties the number rose 33 per cent to top 1,. It was up three-quarters (78 per cent) for women aged 4 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 22, 21, 2, Number of full-time equivalent (FTE) midwives Source: Hansard, and Health and Social Care Information Centre 19, 18, 17, 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

5 England Midwives: monthly figures 22,5 22, 21,5 21, 2,5 2, 19,5 Number of FTE midwives Source: Health and Social Care Information Centre Sept 29 Jan 21 May 21 Sept 21 Jan 211 May 211 Sept 211 Jan 212 May 212 Sept 212 Jan 213 May 213 Sept 213 Jan 214 May 214 Sept 214 Jan 215 May 215 The biggest jump in midwife numbers comes every year between September and November, as newly-qualified midwives are taken on by trusts. In 21 this two-month period saw a rise of 32 midwives, followed by 59 in 211, 578 in 212, 68 in 213, and by 693 in 214. 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 25 who are aged under 5 Age profile of NHS midwives in England 24 2 We need more midwives. Rt. Hon. Jeremy Hunt MP, Secretary of State for Health, 13th October % of total midwifery workforce, 25 % of total midwifery workforce, 214 Source: Hansard, and annual NHS non-medical workforce censuses under and over It is in the age profile of the midwifery profession that the biggest problem lies. Between 25 and 214 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 25 and 214 has been in midwives aged 5 or older. Only 2 per cent (66 midwives out of 3,172) were younger than 5. State of Maternity Services 5

6 England All student midwives 7, 6, 5, 4, 3, Student midwives at any stage in their training Source: ministerial answers to parliamentary questions 2, 1, Academic year 29/1 21/11 211/12 212/13 213/14 We do need to expand maternity provision. Rt. Hon. Jeremy Hunt MP, Secretary of State for Health, 13th October 215 New student midwives 2,5 2, 1,5 1, Student midwife places commissioned Source: ministerial answers to parliamentary questions 5 Academic year 21/2 22/3 23/4 24/5 25/6 26/7 27/8 28/9 29/1 21/11 211/12 212/13 213/14 The number of places for new student midwives reached around 2,5 in 29/1 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

7 England Midwife shortage 25, 2, 15, 1, 5, 3,316 shortage 3,394 shortage 3,999 shortage 4,359 shortage 4,387 shortage 5,174 shortage 5,53 shortage 6,32 shortage 5,367 shortage 5,328 shortage 4,976 shortage 4,787 shortage 3,37 shortage 2,618 shortage Number of midwives Number of midwives required Source: annual NHS nonmedical workforce censuses & RCM calculations We estimate that the NHS in England is short of around 2,6 midwives. This is down on recent years, and much reduced from the high of around 6, in 28. 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, 2,5 2, 7% rise in the number of midwives in North West London between 213 and 214 1,5 1, Number of FTE midwives, % East Midlands % East of England % Yorkshire & the Humber % Wessex +1 +1% Thames Valley % North West London +5 % South London % North Central & East London % Kent, Surrey & Sussex % North East % North West +7 +3% West Midlands +3 % South West Number of FTE midwives, 214 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 213 and 214, whilst South London s workforce was virtually unchanged. State of Maternity Services 7

8 Scotland Live births 6, 58, 56, 54, Number of live births Source: General Register Office for Scotland 52, 5, 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 22 until 28, rising 17 per cent to top 6,. It then remained around that level, dropping back below 6,, Age profile of mothers 8 between 29 and 212. In 213 we saw a small but noticeable (three per cent) drop, to 56,. Last year however the number rose again, up a little over 1 per cent, to 56, % change in number of live births, Source: General Register Office for Scotland under and over The number of births in Scotland to women and children aged under 2 fell 45 per cent between 21 and 214, from around 4,5 to around 2,5. Meantime the number of babies born to women aged in their late thirties rose by 21 per cent and for women aged 4 or over the rise was three-quarters (76 per cent), or by almost 1,. 8 The Royal College of Midwives

9 Scotland Midwives 2,45 2,425 2,4 2,375 2, 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 2,4 for a few years now. We do not believe that, at the national level, there is currently a shortage of midwives in Scotland. Age profile Number of total midwifery workforce, 211 Number of total midwifery workforce, 215 Source: ISD Scotland under and over In Scotland, between 211 and 215, the number of staff (midwives and maternity care assistants) aged under 5 fell by 27 whilst the number aged 5 or over rose by 33. Overall, the percentage aged 5 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

10 Scotland Student midwives Student midwife intake (direct) Student midwife intake (conversion) Source: ISD Scotland Academic year 2/1 21/2 22/3 23/4 24/5 25/6 26/7 27/8 28/9 29/1 21/11 211/12 212/13 213/14 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 in births to women over 4 78% increase in births to women aged 4+ in England 76% increase in births to women aged 4+ in Scotland % increase in births to women aged 4+ in Wales 57% increase in births to women aged 4+ in Northern Ireland 1 The Royal College of Midwives

11 Wales Live births 36, 35, 34, 33, 32, 31, 3, Number of live births Source: StatsWales Just like Scotland, Wales saw a rise in the number of births between 22 and 28; in Wales the increase was 18 per cent, or about 5,5. Also like Scotland, Wales then witnessed a small tailing off Age profile of mothers 2 of the number, before falling noticeably in 213. And in the most recent year for which we have figures, 214, the number pretty much stopped falling, down just.6 per cent on the previous year. 1% rise in births in Wales between 21 and % change in number of live births, under 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 2 and a rise in the number of babies born to older women. In Wales however both changes have been less pronounced than elsewhere. Between 27 and 212, 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 1 per cent. For the oldest age group, women aged 4 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

12 Wales Midwives Number of FTE midwives Source: StatsWales % increase in midwives between 29 and 214 There were more midwives working in the NHS in Wales last year than there have been since at least 29. The increase during that time was 99 Student midwives 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. Number of student midwives (pre-registration) Source: Health Statistics Wales Academic year 28/9 29/1 21/11 211/12 212/13 213/14 The number of places for student midwives in Wales rose from 2 in 28/9 to stand at around 3 during the period 211/12 213/14. 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

13 Northern Ireland Live births 26, 25, 24, 23, 11% increase in births since 21 22, 21, 2, The number of babies born in Northern Ireland has also been very stable in recent years, varying between around 24,5 to 25,5 since 27. As happened in Scotland, last year saw a rise in the number, compared to 213. 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 % change in number of live births, Source: Northern Ireland Statistics and Research Agency under 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 2 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 2,2. And the share of all births that were to women in their early forties doubled. State of Maternity Services 13

14 Northern Ireland Midwives 1,1 1,75 1,5 1,25 1, 975 Number of FTE midwives Source: Department of Health, Social Services and Public Safety fewer midwives in Northern Ireland aged under 5 in 215 than there were in 21 Age profile of midwives % of total midwifery workforce, 21 % of total midwifery workforce, 215 Source: Department of Health, Social Services and Public Safety. 1 5 under 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 5 actually fell in recent years, by 224 between 21 and 215, whilst the number aged 5 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

15 Northern Ireland Student midwives 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 (29 211) before nudging down a little to 6 (212). 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 5 Thousands more midwives since 25, but only 66 were under the age of 5 2% midwives under age rise in midwives over the age of Northern Ireland 224 fall in midwives under the age of England State of Maternity Services 15

16 The Royal College of Midwives Headquarters 15 Mansfield Street London W1G 9NH Report compiled by Stuart Bonar

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