Recent reports are pointing to more midwives leaving in the UK. Leah Hazard, midwife and author, reflects on the reasons for those exiting in the 46-55 age group and points to her personal history as a potential reason.
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The RCM’s recent report on the state of England’s maternity services certainly had some punchy talking points: a national shortfall of 2500 midwives, a significant drop in midwifery applicants, a rise in maternal age and obesity, and a reminder of the unacceptable and persistent gap in maternal health outcomes for Black and minoritised ethnic women and birthing people. The maternity workload is getting more complex, and it remains a challenge to meet clinical needs as we emerge from a pandemic. Perhaps predictably, senior staff in the 46-55 age group are now leaving in their droves. Are older midwives just exhausted, or are there other drivers behind this mass exodus?
The answer is complicated. There’s no doubt that senior staff have borne a very particular burden during the pandemic: their expertise was sorely needed at a time when midwives faced rapid change, new ways of working and the constant threat of a potentially deadly virus. Older staff who may otherwise have retired between 2020 and 2023 may have decided to ‘hang in there’ until the worst was over, then graciously bowed out. But the NMC’s 2023 report indicated that more than half of nurses and midwives who left the register in the past year did so earlier – and almost a quarter did so much earlier – than they had planned. I have a sneaking suspicion that the 46-55 age group makes up a fair amount of that number, and there are two reasons why: perimenopause and menopause.
Menopause – technically the point at which a year has passed since a person’s last period – occurs on average at the age of 51. However, perimenopause – the phase of hormonal change leading up to that final period – often begins several years before menstruation finally stops, and a state of flux may continue for years, or even decades, after menses has stopped. Some women and people who menstruate sail through this transitional time with little or no distress, but others experience troubling physical, cognitive and emotional symptoms, from fatigue, aching joints, tinnitus, dry skin and genitourinary issues to depression, anxiety and brain fog. Not ideal for midwives, whose jobs demand an unflinching ability to cope with immense physical strain and emotional duress, often for long shifts with few or no breaks.
Unfortunately, as a 45-year-old perimenopausal woman, I speak from personal experience. I wish I didn’t. I expected to sail through – even embrace – perimenopause and menopause, having suffered from painful, heavy periods for most of life. I anticipated a joyful, breezy, bleed-free time. Mother Nature had other plans, though, and about 5 years ago, my periods became so brutal that they would often leave me light-headed, shaky and nauseous – a common problem in perimenopause as the ovaries begin to pack up and the body gets its hormonal wires crossed. It’s not easy to manage a 12-hour-shift in the kind of pain that ibuprofen just won’t touch, with blood running out of you like a brisk PPH, and few (if any) opportunities to sit, rest or change your sanitary products.
Perimenopause had other delights in store for me, too: bouts of searing exhaustion that came from nowhere (also common), palpitations (ditto), sudden anxiety (same) and a creeping and ultimately debilitating depression that infused every day with an irrational sense of impending doom. These symptoms were overwhelming enough that I had to take an extended break from work until I figured out what was happening; even a midwife and so-called women’s health expert (other people’s accolade, not mine!) can be bewildered by this strange constellation of symptoms. I could not ‘self-care’ my way out of this dark time; no amount of running, yoga, meditation, journalling or supplements could make a dent in my despair. It took even longer to receive empathetic medical care and to settle on an effective regime of HRT (admittedly, not the solution for everyone, and still not a substitute for pre-perimenopausal me).
Granted, some workplaces do have a ‘menopause policy’ designed to accommodate – or at least, pay lip service to – peri-/menopausal symptoms. Last year, NHS England signed up to the Menopause Workplace Pledge, which includes a promise of flexible working, cooler temperatures and signposts to further resources. In real terms, though, these accommodations may not go far enough for midwives. When I finally returned to work after my self-imposed break, I noticed that a few older staff were wearing newly introduced ‘menopause uniforms’ – polo shirts made from a more breathable fabric than our usual tunics – but the relentless workload and daily stressors were the same as ever.
Putting pledges and promises to one side, there still seems to be a misconception that menopause is just about hot flushes, and that if we simply help staff cool down, then the ‘problem’ of their very human, hormonal, fallible bodies will be solved. While these flushes may indeed be the symptom most people associate with menopause and perimenopause, many women – like me – hardly ever or never experience them. For us, other symptoms like the ones I’ve described above characterise this tumultuous stage of our lives. How does a cool-weave polo shirt combat painful joints, or fatigue, or persistent UTIs? And while a snazzy new uniform might make you feel good in the moment, how do modern midwifery’s overwhelming workload and chronic understaffing alleviate – or more likely, exacerbate – hormonal depression and anxiety?
If the NHS is serious about retaining older midwives, managers need to look carefully at this generation’s bigger picture, including the complex and often life-altering physiological changes of this life stage. It’s ironic that this crucial work has only just begun, as many senior midwifery managers are themselves in the peri-/menopausal age bracket and may well be intimately familiar with the challenges of that phase already.
The NHS needs to go beyond lip service, and fast. We must do better than ‘menopause uniforms’, and we must consider how the current clinical landscape affects staff whose struggles don’t end with the odd hot flush. We need manageable workloads, comfortable environments, guaranteed rest times, reasonable days off between blocks of shifts, and compassionate line managers (for a start). These changes – all of which arguably fall under the umbrella of basic workers’ rights – would benefit the entire workforce, not just those in perimenopause or menopause. And that, in turn, is a win for birthing parents, and a win for the NHS.
By Leah Hazard, midwife and author of The Father’s Home Birth Handbook, Hard Pushed: A Midwife’s Story and Womb: The Inside Story of Where We All Began. Leah’s writing about midwifery and reproductive health has appeared in The Times, The Guardian, New Statesman and more, and she is a regular commentator on these issues across the British and international media.
August 2023
