2025 ended with maternity services in the UK continuing to be under scrutiny for a number of reasons. At the start of 2026 Neil Stewart, Editorial Director for the Maternity and Midwifery Forum, reflects on the state of maternity and poses questions of how things may be improved going forward.
A year ago, this week, I posed the question to the Secretary of State for Health in England:
“Are you resigned and comfortable being the Secretary of State on whose watch 50% of the female of the species give birth by major surgery with virtually no public debate on how this has come about and what it means for child and maternal health?”
Just before Christmas the NHS statistics revealed how this has come to pass, indeed one maternity unit was reported to have reached 80%.
Plus the growing awareness of the turmoil in maternity units and the trauma that women are reporting suffering in the repeated enquiries, the latest of which has shocked Baroness Amos. But we should not be surprised.
“Listening to Women” is, we are told, at the centre of the government’s maternity policy.
Going through the various enquiries reports and the long tail of cases and complaints which did not arise from maternal death or stillbirth we see a consistent theme of women suffering trauma and reporting “not being listened to”.
But within the worst of these cases, and many of them are terrible and beggar belief at the professional mistakes or missed signs of distress in the mother, there is another consistent theme – the woman was sent back home, the woman was not admitted, the woman was discharged home.
What is the reason behind this consistent problem where the woman is not admitted to a maternity unit in time to be monitored or is discharged after birth and sent home without monitoring or support?
Time after time the answer comes back that the unit is full, there are not enough beds.
What is it about the NHS and beds? Why does the NHS run hot to near 95% capacity which easily tips over into 100% and no spare, when other European systems run at 85% occupancy with capacity to spare. I thought I should look at and how we got to this place.
The NHS and its obsession with bed numbers started when it was set up. Consultants stayed independent practitioners in 1948, hospitals were run by governors, administrators and matrons. Consultants, in what is basically a barter system, were offered a number of beds for “their” patients. Controlling and “owning beds” became the negotiated norm.
Maternity at the time was run by local government, midwives and health visitors worked for the council till 1974, most women gave birth at home back in 1948.
As surplus war hospital facilities for the sick and wounded became available the opportunity was seized. The process began to shift to the creation of “maternity homes”, – some of which we might now call birthing centres -managed by GP’s, one of which I was born in near Montrose in Scotland – a big country house / hospital that had been requisitioned during the war and was then available for new NHS services.
That is how many maternity homes began, outside and separate to major hospitals. My mother was driven to the front door for her due date and handed over to the care of the midwives, my father was sent home, not allowed to attend the birth, and then received a call after birth and 5 days of lying in to come and collect her.
Institutionally this was confirmed with the midwives and health visitors being transferred to NHS employment from 1974.
In the 30 years to 1990 the pressures grew for “efficiency savings” but also access to better emergency care. The Labour Secretary of State in the 1970s David Ennal boasted that he closed over 260 hospital as part of that concentration of services but it still left midwifery run units and community based care.
That combined with changes in various doctors’ practices, such as breech birth (C section became the default), due to global research and often driven by insurers and lawyers, led to the closure of many such standalone maternity homes and the move to what we now recognise as maternity units situated within major acute units. Covid and 10 years of scandal and unresolved enquiry reports have done much to complete the concentration of services within acute hospital units. The shortage of midwives has also led to the idea it is good to have as many as possible based out of one place, the hospital.
The excellent access to better emergency services, acute care and neonatal care led to continuing improvement and the expectation of continuing reductions in stillbirth and maternal mortality.
But it also brought the general hospital managerialism of savings culture, just in time, efficiency and the continued demand to “reduce the number of beds”. I have heard many complex and clever arguments as to why a “bed” is a unit of resource measure that makes sense. But I still see it historically as strange that something that was a barter system still dominates the thinking as a mechanism of control of costs in NHS spending.
If you think about the media noise around the NHS you would think that the largest parts of the work of the NHS were cancer, kidneys, heart orthopaedics, dementia research and waiting lists for everything from eyes, ears throat and nose and bowels.
However, a look at the actual numbers of inpatient operations presents a slightly different picture of patients operated on and treated. Plus, some significant differences for pregnant women.
Just looking at Orthopaedic operations, the NHS did about 121,000 in 2023 (but lots more went private and there are long waiting lists). There were 28,000 Cardiac operations (but over 300,000 were on a waiting list).
For maternity services there were 563 561 births in 2023, of which 211,000 were by surgical C- section, but that is, of course around 1,120,000 patients when mothers and babies are included.
There is at least 6 or 7 months notice when women join the service and there can be no waiting list as a way of controlling maternity spending. While other services are limited by capacity, (some would claim managed by waiting lists) maternity has to meet the capacity which it knows is coming.
With the litigation and awards bill for maternity mistakes now exceeding the cost of the maternity service surely there is a case for breaking the link with the acute hospital model, increasing the numbers of beds and midwives to monitor in person to reduce the cases where the woman is mistakenly sent home?
The recent news stories about Oxford Radcliffe highlighted that theatre access was reduced at weekends, a common practice in acute hospitals, but no one has yet managed to persuade babies to follow the rules, arrive before Friday closing or join a waiting list for the following week.
To reduce birth trauma issues and the hidden costs of readmission, increase the number of beds and facilities to enable the choice for a mother to stay in for up to 5 days instead of being sent home in an average of less than 2 days. Ideally there would be better community midwife post-natal services and follow up as well so women had a better choice about when to go home.
In both cases this will need an increased number of midwives to make sure women are really listened to and another 120,000 do not have emergency C-Sections in 2026 which they did not choose, plan for or expect the trauma associated with them.
If the enquiry by Baroness Amos and the Taskforce set up by the Secretary of State can break out of that managerial mindset of seeing childbirth as just another one of the acute hospital services to be measured by beds, they can bring an end to the relentless stream of stories of scandal enquiries in maternity units and avoid maternity services being added to what the politician and commentators call “state failures”, where they never seem to be able to find a settlement to the hamster wheel of distressing news stories undermining public confidence in the service.
Many of the answers are already in the public arena in the Renfrew Report on Northern Ireland published in 2024, but my challenge is to address the lack of “lying-in facilities” before and after birth to give back to women the chance to be listened to. That is my wish for 2026.
January 2026
Neil Stewart
Editorial Director, Maternity & Midwifery Forum