Maternity services are facing increasing pressures - a rising birth rate, an increasing number of complex pregnancies and births, and changes in practice that are leading to more inductions.
And this year we had the publication of Better Births, the report of the national maternity review in England. The report states that maternity services in England are expected to develop services that are safer, more accessible and which offer women more personalised care.
But this increased demand on maternity service capacity is outstripping the supply of available midwives and maternity support workers. As well as a continuing shortage of midwives, there is an ageing workforce (many midwives will be eligible to retire in the next five to ten years) and fear that the ending of the student bursary will lead to fewer applying to study midwifery. Add in the current squeeze on NHS funding and maternity services simply isn’t employing sufficient midwives.
For women this means that whilst most maternity services meet recognised standards of care for women in labour, antenatal care is often disjointed. There is considerable variation in the quality of postnatal care. There aren’t enough specialist midwives to care for women with particular medical and/or social needs. And as a result of staff shortages, midwifery units are sometimes forced to temporarily suspend services.
For midwives this means a long hours culture, excessive workloads, little support for continuing professional development, an overuse of agency staff, and high anxiety caused by continually feeling unable to give of their best.
Of course it is not only the maternity workforce that is under pressure from increased demands and constrained resources. Similar challenges affect nurses, leading to the development of new roles such as that of nursing associates. Meanwhile shortages of doctors, particularly in staffing junior doctor rotas, is leading to discussions about nurses undertaking advanced practitioner roles.
So how can we ensure safe and effective staffing?
In a brand new report Getting the midwifery workforce right the Royal College of Midwives explores the extent to which the midwife’s role – and their relationships with other professionals and care givers – can or should change.
The report stresses that midwifery services should be staffed in a way that enables women to receive the majority of care from a small group of midwives they know and trust.
The role of the midwife can encompass new tasks, but these should be consistent with the interests of women and their babies, properly resourced, supported by defined competencies and appropriate education and within their scope of practice.
It is not appropriate for a midwife to undertake tasks which are better performed by other professionals, from scrubbing in theatre to undertaking ventouse deliveries (though there may be exceptions in specific local circumstances, usually relating small units in rural settings).
There is no need for a nursing associate role in maternity services. Resources should instead be focused on supporting the role of Maternity Support Workers, who make an important contribution to the care given to women and families, through developing nationally agreed competencies and national training programmes.
And rather than a new advanced practitioner role, maternity services should be employing more consultant midwives. Consultant midwives already have a clinical, educational, leadership and research role across a wide midwifery setting and they make an enormous contribution to the clinical leadership and practice development within a unit.
A modern maternity service should be flexible and adaptive. New technologies, digital healthcare, new challenges and changing demographics all demand the provision of maternity services that are open to change and to new ways of working.
But it is just as important to avoid hasty, financially-driven solutions that may reduce continuity, impede holistic care, lower standards, worsen inequalities or de-skill midwives.
The overarching challenge facing maternity services is that there are simply not enough midwives and maternity support workers currently working in the NHS. If the NHS is serious about delivering the quality and standard of maternity care that it aspires to, then it has to increase the number of midwives that it employs.