#soms2013

State of Maternity Services report 2013

1 | The Royal College of Midwives

Executive summary
This is the third report in our annual State of Maternity Services series. Our two previous reports, the 2011 and 2012 editions, have set the standard as go-to points of reference for the latest numbers on NHS maternity services for each part of the UK. Over time the reports will serve as an evolving commentary on the changing state of maternity services; meantime they provide commentators and decision-makers with a snapshot of todays maternity care. The report is not a review of, say, structural changes. It has a very specic focus: the collation and interpretation of some of the basic numbers that tell the story of the state of maternity services. England remains the problem child. The number of births in England continued to rise in 2012, reaching its highest number (694,241) since 1971. This was 23 per cent higher than 2001. London (up 29 per cent) along with the South West and the East Midlands (both up 25 per cent) are the regions that have seen the biggest rises. In Scotland, births fell for the fourth year in a row, although remained 10 per cent higher than in 2001. In both Wales and Northern Ireland the number of births fell in 2012 for the second year in a row, but in both cases the number remained 15 per cent higher than it had been in 2001. The very latest gures, for the rst half of 2013, may however suggest that the baby boom in England is over. In the rst six months of the year the number of births in England fell by 18,000, compared to 2012. Smaller falls in the rst six months of 2013 were seen across the rest of the UK. Scotland, Wales and Northern Ireland have thankfully not used the tailing off of their baby booms to cut midwife numbers. Whilst individual units or areas in those parts of the UK may be understaffed, overall they employ broadly the right number of midwives. The effect of this higher number of births in England is multiplied by the growing complexity of pregnancies. Indeed, the importance of complexity on the midwifery workload has often been overlooked. One example of rising complexity is the continuing growth of births to older women. In 2012, for example, there were 85 per cent more babies born to women in England aged 40 or over than there had been in 2001. In Scotland the rise for mothers aged 40 to 44 was 71 per cent over the same period, and 165 per cent for women older than that. In Wales the rise was 64 per cent for births to women aged 40 or over. And in Northern Ireland it was 64 per cent for women between the ages of 40 and 44, and 53 per cent to women above that age range. The total number of students studying midwifery has now topped 6,000 in England. That is good news, and needs to continue. The UK Government increased training places in England to a record level before letting them slip back in 2013/14; they should return the number of student places to their record level. The fact that the NHS in England is thousands of midwives short of where it needs to be was conrmed in November 2013 by the publication of the National Audit Ofce (NAO) report, Maternity services in England. The reports ndings largely conrmed what the RCM has been saying for some years now. Outside of England, we need politicians to ensure that they keep putting into NHS maternity services the resources required to maintain everything on an even keel, particularly keeping an eye on the age prole of midwives so that retirees are replaced in good time by newly-qualied staff. Within England we need to see an explicit commitment to maintain and speed up the elimination of the midwife shortage. A cut in the shortage of 200 midwives in a year is okay, but it is by no means fast enough. We need to see training numbers maintained at their current levels and newly-qualied midwives given employment not least because of the growing dropout rate amongst student midwives, as referenced in the NAO report. Above all it is important for the RCM to communicate the fact that any falling away of the baby boom should not be seen as a reason to take a foot off the accelerator; instead, it should be seen as an opportunity to eliminate the shortage much faster. We remain hopeful for better days ahead. It would appear that the baby boom may have ended, although birth numbers remain high. With the pressure easing, the opportunity is now here nally to eliminate Englands longstanding midwife shortage.
1

Any falling away of the baby boom should not be seen as a reason to take a foot off the accelerator
Obesity is another area of growing complexity, which compounds the effect of the baby boom1. The incidence of maternal obesity in the rst three months of pregnancy in England, for example, more than doubled from 7.6 per cent to 15.6 per cent between 1989 and 2007. The result is an extra 47,500 women requiring more demanding care. Our assessment of the shortage of midwives in the NHS in England in 2012, the latest full year for which we have both midwife and birth gures, is around 4,800. This is an improvement of 200 on last year. Indeed, this is the fourth year in a row in which the shortage has fallen, having stood at more than 6,000 in 2008. This report also publishes for the rst time a calculation, for England, of the difference between the number of births that took place in a year and the number of births for which the midwifery workforce during that year was suited. So, for example, in 2012 there were 694,241 babies born in England, but the number of midwives working in the NHS in that year was only really suitable for 565,245 births; meaning there were 128,996 more births than the service was designed to cope with. This puts any recent reduction in the number of births in context.

Heslehurst, N. and Rankin, J. and Wilkinson, J.R. and Summerbell, C.D. (2010) A nationally representative study of maternal obesity in England, UK: trends in incidence and demographic inequalities in 619323 births, 1989-2007., International journal of obesity., 34 (3). pp. 420-428.

2 | The Royal College of Midwives

England
Births
700000
700,000 Number of live births JanMar Number of live births AprilJune Number of live births JulySept Number of live births OctDec Source: the Ofce for National Statistics

600000
600,000

500000 500,000 400000 400,000 300000 300,000 200000 200,000 100000 100,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Between 2001 and 2012 the number of births each year rose by 130,497 (or 23 per cent). Last year (2012) saw more babies born in England (694,241) than any year since 1971. Figures for the rst half of

2013 however show that the number of births is beginning to fall, compared to the same period in 2012, suggesting that the decade-long baby boom may have come to an end.

increase in babies born between 2001 and 2012

23%

Regional variation in births

135,000 135000 120,000 120000 105,000 105000 90,000 90000 75,000 75000 60,000 60000 45,000 45000 30,000 30000 15,000 15000 0 0 Number of live births, 2001 Number of live births, 2012 Source: the Ofce for National Statistics

+14,010 +19%

+11,783 +21%

+11,003 +25%

+13,122 +22%

+14,481 +24%

+30,024 +29%

+19,348 +22%

North East

North West

Yorkshire & the Humber

East Midlands

West Midlands

East of England

London

South East

South West

All but two English regions saw rises of above 20 per cent between 2001 and 2012, with the biggest rises seen in London (up 29 per cent) as well as the South West and the East Midlands (both up 25 per cent). The largest rises in the number of babies born each year were in London (up 30,024) and the South East (up 19,348).

The lowest rises over those 11 years were seen in the North East and the North West, but those rises were still 17 and 19 per cent respectively.

+12,384 +25%

+4,342 +17%

State of Maternity Services | 3

England

Age prole of mothers

80 80 70 70 60 60 50 50 40 40 30 30 20 20
% change in number of live births, 2001-2012 (England and Wales) Source: the Ofce for National Statistics

10 10 0 0 -10 -10 -20 -20

under 20 20-24 25-29 30-34 35-39 40 and over

Previous State of Maternity Services reports revealed a trend towards women having babies later in life, and fewer giving birth in their teenage years. These trends are becoming more pronounced. Between 2001 and 2012, for example, the number of babies born in England to women aged 40 or over rose by 85 per cent (up 13,280).

these women up 33 per cent. At the other end of the scale, babies born to women and girls aged under 20 fell 23 per cent during this period. Older women require more assistance from midwives. They have a perfect right to all that additional care, of course, but it has an undeniable knock-on effect on workload, and that needs to be reected in the number of midwives in the NHS overall.

increase in births to women aged 40 and over between 2001 and 2012

85%

The second-highest rise amongst the age groups was to women aged 35 to 39, with babies born to

Midwives
21000
21,000

20000

20,000

19000

19,000

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

18000

18,000

17000 17,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

The number of midwives is up. In 2012, at the annual snapshot date of 30th September, there were the equivalent of 20,935 full-time midwives working in the NHS in England. This was up over
4 | The Royal College of Midwives

3,000 since the start of the baby boom in 2001. For most of the last decade, the midwifery workforce has risen slower than the number of births, though this has improved in recent years.

England

Midwives: the Coalitions record

21500 21,500

21200 21,200

20900 20,900

20600 20,600
Number of full-time equivalent (FTE) midwives, England Source: Health and Social Care Information Centre May 2010 Aug 2010 Nov 2010 Feb 2011 May 2011 Aug 2011 Nov 2011 Feb 2012 May 2012 Aug 2012 Nov 2012 Feb 2013 May 2013 Aug 2013

20300 20,300 20000

20,000

The RCM is willing to criticise where it sees the Government getting things wrong, but equally we want to praise where we see the Government getting things right. On midwife numbers the Government is moving things in the right direction. Despite cuts elsewhere, we have seen a continued rise in midwife gures since 2010, continuing a rise that started under

Labour. Indeed, there were 19 per cent (or 3,364) more midwives in 2012 compared to 2001. The number of NHS midwives in England is up over 1,200 since the 2010 election, but has dipped slightly in recent months; with the desperate need for more midwives, we do hope that this drop will prove temporary.

increase in midwives between 2001 and 2012

19%

Age prole of midwives

24
24

20
20

16
16

12
12

8
8

% of total midwifery workforce, 2001 % of total midwifery workforce, 2012 Source: annual NHS nonmedical workforce censuses under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 and over

4
4

0
0

NHS midwives in England are getting older. The largest age group in 2001 was midwives aged between 35 and 39; the largest age group in 2012 was those aged 45 to 49.

In other words, that large group is working its way through the system. Workforce planners need to ensure that this large group of midwives is replaced in advance of retirement.
State of Maternity Services | 5

England

Student midwives
2500 2,500

2000 2,000

1500 1,500

1000 1,000

Student midwife places commissioned, England Source: ministerial answers to parliamentary questions

500 500

0 0
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 2012 Academic year

The Coalition deserves praise for increasing the number of training places for midwives. The total number of student midwives in 2012/13 topped 6,000, which is excellent news. In the most recent year (2013/14) the number has dropped slightly, which is a shame.

As stated earlier, the work to eliminate the shortage must be maintained; the RCM wants to see the number of places for new student midwives restored to its earlier, record level. There is absolutely no shortage of applicants for midwifery courses.

How births outstrip midwife numbers

Number of births between 20012012, England Number of births that could be guaranteed good quality care based on the size of the midwifery workforce Source: annual NHS non-medical workforce censuses & RCM calculations Note: All gures 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.
700000 700,000

600,000 600000 500,000 500000

400000 400,000

300000 300,000

200000 200,000

100000 100,000

0 0

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

This report introduces a new measurement: the difference between the number of births that take place each year and the number of births for which the midwifery workforce is suited. So, for example, in 2012 there were 694,241 babies born in England, but the number of midwives working in the NHS in that year was only really suitable for 565,245 births; meaning there were 128,996 more births than the service was designed to cope with.

So, even if the baby boom has ended and the number of births falls in 2013, it would need to drop by around 130,000 before the need for more midwives no longer exists. The end of the baby boom, if that is what we are seeing, does not mean the end of the need for more midwives.

6 | The Royal College of Midwives

England

Regional changes in number of midwives

4000 4,000 3500 3,500 3000 3,000 2500 2,500 2000 2,000 1500 1,500

Number of FTE midwives, 2001 Number of FTE midwives, 2012 Source: Health and Social Care Information Centre

+1,373 +52%

+273 +15%

+190 +14%

+297 +14%

+581 +39%

+479 +42%

-117 -4%

+51 +5%

500 500

00

North East

North West

Yorkshire & the Humber

East Midlands

West Midlands

East of England

London

South East Coast

South Central

South West

There is a big variation in how different parts of England have responded to the baby boom. The NHS in London, for example, increased the number of full time equivalent midwives between 2001 and 2012 by more than half; up from 2,633 to 4,006. NHS South East Coast increased their midwife numbers by 42 per cent, or 479 midwives, and the East of England witnessed a 39 per cent boost, up from 1,501 to 2,082.

The smallest rise was seen in the North East (up just 5 per cent), although to be fair it went into the baby boom in a far healthier state than any other region. The worst performer was the North West, where the number of midwives was actually cut by 117 midwives between 2001 and 2012, despite the number of babies born in the region jumping by 14,010 over the same period.

+95 +5%

1000 1,000

+139 +11%

drop in the number of midwives in the North West between 2001 and 2012

4%

State of Maternity Services | 7

Scotland
Births
60000
60,000

58000

58,000

56000

56,000

54000

54,000

Number of live births, Scotland Source: General Register Ofce for Scotland

52000

52,000

50000

50,000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

2012 was the fourth successive year in which the number of babies born in Scotland fell. The drop between 2008 and 2012 was not dramatic; the

2012 gure for births (58,027) was only 3.4 per cent off the 2008 peak (60,041), and the 2012 gure was still 10 per cent higher than 2001.

fall in births to girls under 20 between 2001 and 2011

24%

Age prole of mothers

160 160 140 140 120 120 100 100 80 80 60 60 40 40 20 20
% change in number of live births, 2001-2012 (Scotland) Source: General Register Ofce for Scotland 00

-20 -20 -40 -40

under 20 20-24 25-29 30-34 35-39 40-44 45 and over

The changing age prole of women giving birth throughout the UK is perhaps at its most extreme in Scotland. The number of births to women and girls aged below 20, for example, fell 31 per cent between 2001 and 2012, from 4,444 to 3,074.

For older mothers, the care of growing numbers of whom is placing additional pressure on the NHS, rose dramatically in Scotland. The number of babies born to women aged between 40 and 44, for example, was up 71 per cent between 2001 and 2012; for the oldest age group (45+) the increase was 165 per cent, although for women of that age the numbers of birth are small (up from 40 to 106).

8 | The Royal College of Midwives

Scotland

Midwives
2,700 2700

2,600 2600

2,500 2500

2,400 2400

Number of FTE midwives (bands 5-9), Scotland Source: ISD Scotland

2,300 2300 2007 2008 2009 2010 2011 2012 2013

Sensibly the Scottish Government has not exploited a small reduction (3.4 per cent over four years) in the number of births to slash midwife numbers. They have maintained them and we welcome the fact that they have taken that course of action.

We believe that the apparent fall in midwives shown in the chart is as a result of a large-scale data cleansing exercise, and that in recent months the gures have become much more accurate and trustworthy. The RCM believes that, when viewed as a whole, the NHS in Scotland employs enough midwives.

Student midwives
250 250 225 225 200 200 175 175 150 150 125 125 100 100 75 75 50 50 25 25
00 Academic year 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Source: ISD Scotland Student midwife intake (initial intake), Scotland Student midwife intake (conversion), Scotland

The number of training places for midwives in Scotland was cut. We accept that as reasonable however given that the NHS in Scotland employs sufcient numbers of midwives and the baby boom has tailed off.

The RCM will not simply call for more midwives, more student midwives and more funding whatever the circumstances. If we believe that a part of the UK employs enough midwives we will say so.

State of Maternity Services | 9

Wales 15%
Births
36000 36,000 35000 35,000 34000 34,000

rise in births in Wales between 2001 and 2012

33000 33,000

32,000 32000

Number of live births, Wales Source: StatsWales

31,000 31000

30,000 30000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

In 2012, the number of babies born in Wales fell; this was the second year in a row in which it had fallen. Between 2010 and 2012 however the

fall was only 2 per cent, down from 35,952 to 35,238. The 2012 gure was still 15 per cent higher than 2001.

Age prole of mothers

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

-10 -10
% change in number of live births, 2001-2011 (Wales) Source: StatsWales

-20 -20 -30 -30 -40 -40

under 16 16-19 20-24 25-29 30-34 35-39 40 and over

Wales has witnessed the same changes in the age prole of mothers seen elsewhere in the UK, i.e. fewer younger mothers, and more older mothers. The small number of births to girls (those aged under 16) dropped 42 per cent between 2001 and 2011, from 93 to 54. There was a 23 per cent

fall in births to the remaining teenagers (ages 16-19) from 3,075 in 2001 to 2,365 in 2011. The biggest rise was to the oldest age group, in Wales that is 40+. The number of births to these women in Wales rose 64 per cent.

10 | The Royal College of Midwives

Wales

Midwives
1350 1350

1300 1300

1250 1250

1200 1200

1150 1150
Number of midwives, Wales 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: StatsWales

1100 1100

Since 2001 the number of midwives in the NHS in Wales has never been lower than 1,120 (in 2002) or higher than 1,323 (in 2008). In 2012 it stood at 1,223, up on the previous year and 8 per cent higher than 2001.

As with Scotland, we estimate that the NHS in Wales employs a sufcient number of midwives.

increase in midwives between 2001 and 2012

8%

Student midwives
320 320 300 300 280 280 260 260 240 240 220 220 200 200 180 180 160 160 140 140 120 120 100 100
Academic year 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 Number of student midwives (preregistration), Wales Source: Health Statistics Wales 2012

We are happy with midwifery training levels in Wales. The gures show a steady increase in places, which should ensure that those moving towards retirement are replaced long before they

leave the profession with newly-qualied midwives who have the time to develop their skills, condence and experience.

State of Maternity Services | 11

Northern Ireland
Births

increase in births since 2001

15%

26000 26,000 25000 25,000 24000 24,000 23000 23,000 22000 22,000

Number of live births, Northern Ireland 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 Irelands shared border with the Republic of Ireland, a signicant number of non-residents also give birth in Northern Ireland, increasing the pressure on maternity services.

21000 21,000 20000 20,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

The situation with births in Northern Ireland is very similar to that of Wales. The number of babies born in Northern Ireland in 2012 (25,269) had fallen for the second year in a row, but by only a tiny amount (down 0.2 per cent in two years).

As with Wales, the 2012 gure was 15 per cent higher than the number of births in 2001. So, as with not just Wales but Scotland too, birth gures in Northern Ireland in 2012 were on a raised plateau compared to recent years, slightly off the peak but well above gures from the start of the century.

Age prole of mothers

60 60

50 50 40 40 30 30 20 20 10 10 0 0
% change in number of live births, 2001-2012 (Northern Ireland) Source: Northern Ireland Statistics and Research Agency

-10 -10 -20 -20 -30 -30

under 20 20-24 25-29 30-34 35-39 40-44 45 and over

The changes in the age prole of mothers in Northern Ireland between 2001 and 2012 were similar to other parts of the UK. Births to the youngest women and girls, those aged under 20,

fell by 28 per cent. The largest rises were to the oldest two age groups; births to women aged 40-44 jumped 64 per cent and for women aged 45+ the number was up 53 per cent.

12 | The Royal College of Midwives

Northern Ireland

Midwives
1040 1,040 1020 1,020 1000 1,000 980 980 960 960 940 940 920 920 900 900
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of FTE midwives, Northern Ireland Source: Department of Health, Social Services and Public Safety.

The number of midwives working in the NHS in Northern Ireland in 2012 was its highest since at least 2001, at 1,040. That was up 7 per cent, or 65 full time equivalent midwives, between 2001 and 2012.

The RCM believes that the NHS in Northern Ireland employs a sufcient number of midwives.

Age prole of midwives

25
25

Northern Ireland midwives were aged 45 or older by 2012

55%

20
20

15
15

10
10

% of total midwifery workforce, 2001 % of total midwifery workforce, 2012 Source: Department of Health, Social Services and Public Safety. under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 and over

5
5

0
0

Midwifery in Northern Ireland is an ageing profession. Midwives falling into the following age bands 25 to 29, 30 to 34, 35 to 39, and 40 to 44 all formed a smaller proportion of the workforce in 2012 compared to 2001.

Interestingly the largest age group in 2001 was 40 to 44, whilst the largest age group in 2012 was 50 to 54, suggesting, possibly, that that represents a particularly large group within the profession in Northern Ireland who are all ageing together. That could present a workforce planning problem, and we would urge the Northern Ireland Executive to keep that under specic observation.

State of Maternity Services | 13

Northern Ireland

Student midwives
70 70 60 60 50 50 40 40
Number of student midwives, direct entry, Northern Ireland Number of student midwives, short course, Northern Ireland Source: Northern Ireland Statistics and Research Agency

30 30 20 20 10 10 0 0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Whilst the latest 2012 student midwife gures are down on recent years, they are still higher than they were prior to 2008, and well above the levels seen at the start of the century.

As with Wales, we hope that this will ensure that new midwives can come into the profession in good time to replace those slowly heading towards retirement. This is something we may explore more in the preparation of the 2014 State of Maternity Services report.

14 | The Royal College of Midwives

Baby Boom 2001 & 2012

% increase
2012
England saw more births in 2012 than any year since 1971

23

Big rise in births to women over 40

2001

71%

increase in births to women aged 40-44 in Scotland

% increase in births to women aged 45+ in Scotland

165

29%

increase in London

10%

increase in Scotland

64%

15% 25%

increase in births to women aged 40-44 in Northern Ireland and Wales

53%

increase in Wales

increase in births to women aged 45+ in Northern Ireland

increase in the South West

15% 25%
increase in the East Midlands

increase in Northern Ireland

2012

2001

increase in births to women aged 40-44 in England

85%

Not enough midwives to guarantee good quality care

2011

2012

52%

2012 2001

increase in midwives in London

2001

2012

In England, the shortage of midwives fell by only 200, from 5,000 in 2011 to 4,800 in 2012.

4%

decrease in midwives in the North West

State of Maternity Services | 15

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