2023 was a challenging year for maternity and midwifery services in the UK globally. Neil Stewart, Editorial Director for the maternity and midwifery forum reflects on what has been happening and looks forward to things improving in 2024.
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So farewell to 2023, a depressing year for the standing of UK maternity and midwifery services, and a global picture not much improving either.
The start of a new year is usually a time for optimism and resolutions. But I think we need to start with some hard realities and see our maternity and midwifery services as others see them and, in a wider demographic context, to understand the scale of the challenges ahead.
Progress stalled
The post war expectation, fulfilled by the NHS, advances in medicine and new healthcare systems around the world, that things would only get better, even if at different speeds, is now being challenged by disappointing statistics and comparative reports – trends that started before the COVID pandemic and continue after.
Confident millennial 2000 projections of increasing childbirth and population numbers and improvements in maternal and infant mortality have stalled and, in some cases, got worse since 2015-16.
Hostile reporting
The other trend that is worse is the reporting of maternity and midwifery stories in the media, which have taken a hostile and negative turn, not without cause, on the back of maternity scandals and critical reports. While the risk of childbirth is not significantly rising the fear of childbirth is and the fear of risk leading to more interventions and caesarean sections and the two are likely connected.
2023 in the UK ended with the reporting of CQC inspections telling pregnant women that 65% of maternity services are rated “inadequate”. To most readers that would mean “unsafe”. The report didn’t actually say unsafe, but why get in the way of a good headline? Nonetheless the figures are getting worse with “inadequate” rising from 6% to 10% (9 units to 18 units), so no room for complacency, and plenty of units needing “improvement” most of which would be solved with better staffing.
The confusing and counterproductive terminologies of OFSTED style inspections, incidentally, being abandoned in school teaching, are being highlighted in the reporting of maternity services inspections – maternity needs a health minister to spot the depressing effect this had on teaching and produce a clearer, fairer system in the NHS that mothers and maternity staff can understand, rally around improvements and trust as fair and safe.
Scale of birth trauma
In October MP’s in the House of Commons ” discovered” birth trauma – parliamentary discovery lags behind professional lessons but is the moment where something understood in the profession bursts as a shock onto the public mind, usually via the BBC Radio4 Today programme. In a Commons debate on 19th October, the details of which would put many women off risking pregnancy, MP’s described the long tail of their own and their constituents multiple kinds of birth traumas from physical, to mental and administrative- some first highlighted and revealed in the Ockenden report the year before. On the positive side MP’s called for a long series of actions on staffing and safety that midwives leaders have also been calling for, so hopefully 2024 will be the year for action.
Maternal deaths
Earlier the MBRRACE report in the autumn said maternal deaths were up 15% compared to 2009-11 when they are targeted to be down 50% by 2025 – a target that is clearly not going to be met unless 2024 is a year of dramatic or revolutionary change. Meanwhile the maternal death rate among women of black and African heritage remained 4 times that of white Caucasian mothers. In the USA the figures are even more shocking. The USA maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019- things can go backwards.
Internationally, the WHO reported that progress on maternal and infant mortality had “stalled” since 2015 - even allowing for the pandemic, progress has stopped.
Falling childbirth rates in the UK
All this is against a big picture of a dropping birth rate in UK (and most of western Europe). Births in England and Wales peaked at 723,913 in 2011 and fell to 605,479 in 2022. If you have ever wondered why it is so hard to win the RCM demand for 3000 more midwives it may be because buried in the UK Treasury there will be an economist planning on the basis that you needed around 1 midwife for every 30-35 births; so on these numbers of 118434 less births you surely need 3000 LESS midwives not more. Schools in London are short of pupils as the drop works its way through.
Arguments for more midwives highlighting retirement rates, retention problems or about older mothers, obesity, more complex conditions, co-morbidities and rising C section rates get lost in translation. We have 700 more midwives than a decade ago, with 118,000 less babies-better ratios SHOULD have produced better results.
Global trends in birth rates
China is struggling to raise its childbirth rate as it reverses its one child policy, with only Africa and pockets of Latin America and the east keeping up their birth rate, which is why the immigration and migration problems will be likely to stay with us for a whole generation as the work and the people to do the work are in different countries.
Workforce implications
We can already see the Implications for workforce here in the UK where 50% of new entries on the nursing and midwifery register were from overseas. Those extra 700 midwives are not home grown. There is a plan to increase midwives in education, but it is running up a down escalator at the moment.
The UK is not alone in facing this demographic speed of change. Policy makers have been slow to respond. What might have been a great opportunity to improve the maternity healthcare for mothers and babies looks like it could be slipping away.
And on top of this change comes the “cost of living crisis” which now has surveys showing 50% of women delaying having children over financial fears.
There are 70 elections taking place worldwide in 2024 with half the population of the world going to the ballot box-including the UK and USA. Not all will be fair or open, but virtually all of them give the vote to women. Will childbirth and maternity rights hit the agenda? Can midwifery tap into that simple fact and get improvements front and centre of the public debate? Women increasingly have the choice on how many children to have, that is right, but once they do become pregnant, they deserve the best of care and too many services are falling short, and internationally some are falling backwards. When midwifery values and demands are aligned with the demands of women, they should be unstoppable.
The Maternity and Midwifery Forum will keep reporting the positive progress being made in maternity services and support maternity and midwifery staff who speak up for maternity, maternal and infant safety, but commanding and mobilising the confidence of women will be key to unlocking government resources and policy in 2024.
Neil Stewart
Editorial Director, Maternity and Midwifery Forum
January 2024