“I’ve had shifts where I’ve gone home crying, it just felt so unsafe,” says Heidi (not her real name). She has been a junior midwife for just two and a half years, and she’s already had enough. Unluckily for her, she began her career in a north-western English hospital at the height of Covid. The extreme short-staffing intensified by the pandemic was a brutal introduction to the profession. “Take the postnatal ward, for example,” she says. “There should be three midwives and three support staff present. But I’ve worked days when there were just two midwives, and that’s it. When you think of the near misses in those conditions, it’s just terrifying, the weight of responsibility.”

The image of the calm, smiling midwife accompanying parents-to-be through one of the most challenging (and hopefully rewarding) experiences of their lives is one that is strong in the public imagination, and it undoubtedly attracts many young people (mainly women) to the profession who are passionate about caring for others. Yet despite continued recruitment of new midwives, recent years have seen maternity services across the National Health Service (NHS) – the UK’s publicly funded healthcare system – struggling to retain them, leading to critical shortages in the workforce. NHS England figures for September 2021 to September 2022 show that the annual number of midwives leaving the profession actually outstripped those joining it – this was not even the case for other health professionals like doctors and nurses, despite attrition being an issue across the healthcare system.

“Around 18 months ago, we began to consistently see each month a year-on-year fall in the number of midwives in post,” says Sean O’Sullivan, head of health and social policy at the Royal College of Midwives (RCM), the main trade union representing midwives in the UK.

“This data has been collected since 2009 and it’s the first time we’re seeing this. In December 2022, for example, there were 100 fewer midwives compared to December of the previous year. The NHS has actually recently put funding into creating more posts, but it’s not managing to fill them.”

Covid-19 undoubtedly had a big impact on staffing and the accompanying stressors, with many midwives not able to come into work, often leaving a too small number to man the fort. However, when it comes to the current rates of attrition, it is clear that the pandemic merely inflamed multiple underlying issues. Heidi emphasises that while the effect of the pandemic was “massive”, “staffing levels turned out to be not just about Covid. We thought it’d just be a short-term thing but it’s still going on. These aren’t new problems. It’s always been understaffed, it’s just getting to the point now where people are struggling to handle it. We lost staff at my hospital, people had just had enough. They know we can cope with it, but it doesn’t mean we should.”

“Midwives have been going above and beyond”

Kay King, movement director of the White Ribbon Alliance, a global non-profit alliance advocating for women’s health rights, agrees that the problems in the profession are both far-reaching and a long time in the making. ”I’m a bit hesitant to link it to the pandemic,”says King, who has also been working as a doula for the past 12 years, is on the steering committee of ‘March with Midwives’, a campaign group that was created to raise awareness about the crisis in the profession. “It’s significant, but the crisis in midwifery is not due to the pandemic: it’s the culmination of a perfect storm. Midwives have been going above and beyond, as they always do. But people are burning out. The main word coming out of recent reports is ‘coping’. They’re not calling it a calling anymore.”

The annual NHS England staff survey for 2021-2022 found that midwives – along with paramedics and ambulance workers – reported experiencing particularly high rates of work-related stress amongst the various NHS occupations, at 62.8 per cent. When it came to the question of work pressure, midwives were the occupation the least likely to agree that they were ‘able to meet all the conflicting demands on their time at work’ (only 20.3 per cent), while 81.4 per cent said they worked additional unpaid hours. Some 48.1 per cent said they often thought about leaving their organisation. For midwives in particular, only 14.1 per cent claimed to be ‘satisfied’ or ‘very satisfied’ with their pay in 2022.

The NHS was hit by a widely publicised cross-occupational pay dispute and industrial action over 2022-2023 in the context of the cost-of-living crisis. But according to O’Sullivan of the RCM, there are wider key issues beyond pay that also need to be tackled if the NHS wants to do better at retaining its midwives. These include providing greater opportunity for professional development (many midwives simply do not have the time to take advantage of learning opportunities) and more flexible working. “Many have care responsibilities, or they just want a life outside of work,” he says. “And some employers are very rigid.” This chimes with the NHS staff survey results. On the question of work-life balance, only 31.9 per cent of midwives felt satisfied with opportunities for flexible working patterns.

Not like on TV

Even at full staffing levels, being a midwife in the NHS is no walk in the park. ”I do three 12.5-hour shifts a week,” says Heidi. “I never get a break, sometimes not even my lunch break, and I never go home on time. And it’s the same everywhere.” The intense rhythm can already begin at the study stage. Midwifery students have to do (unpaid) ‘placement blocks’ in maternity services as part of their degree, and there have been reports of them having to fill absent places, which Heidi confirms from personal experience as well as what she has learned from her peers. “Surveys have shown that 96 per cent of students have had mental health problems and are already at burnout stage. My own coursemates have already left or moved to other services.” They have a financial headache too, since the midwifery study bursary was abolished in 2017 and tuition fees were introduced at £9,250 (approximately €10,785)a year.

Kate Pearce, midwifery lecturer at the University of Greenwich, is unambiguous about the practice of filling places: “It is not allowed. Students should be supernumerary. Lines can become blurred when there is short-staffing, which there almost always is.” Pearce believes that several popular British TV shows of recent times, such as the BBC drama series Call the Midwife and the Channel 4 documentary series One Born Every Minute have potentially played a role in attracting many young women to the profession. “But once they’re on the course, they realise how hard it is.” While no longer at the coalface, Pearce loved her time as a midwife, but she admits that “there does seem to be more pressure than there used to be.” Along with many midwives (including the retired), Pearce came back briefly to practice during the pandemic. But these midwives are now leaving again.

Soo Downe, professor of midwifery studies at the University of Central Lancashire, suggests that some changes in the working conditions of NHS midwives over the years could be contributing factors to what she describes as a situation of “burnout, moral distress, compassion fatigue, and, eventually, disillusionment” experienced by some staff.

“The change from 7-8 hour shifts with relatively long overlaps between them to 12-hour shifts has had some negative effects in my view. When the 7-8 hour shifts were operational, the overlap allowed for multidisciplinary training, for sitting and talking over cases with colleagues, for time to learn from others while chatting about the events of the day, and, as a consequence, gave the opportunity to build effective teams.” Such conditions, she says, may have helped to create a “downward cycle”, where “loss of staff means more pressure on those who stay, who then leave due to the pressure of being short-staffed”.

When it comes to healthcare, a degradation of working conditions evidently creates a double layer of concern, with an impact that goes beyond the employees themselves to touch the wider public. Leah Hazard is both a practising NHS midwife of 10 years in Scotland and an author of several books about midwifery and reproductive health. “It used to be the gold standard and common practice that women would have one-to-one care in active labour,” she says, choosing her words carefully. “…And that does still happen most of the time, in most places…[.] But increasingly it’s not happening, and midwives are looking after numerous people in labour, which has all kinds of potential consequences for the safety of the birthing person and the baby. It’s very difficult to provide the care that you know you’re capable of giving when you just don’t have the human resources to do that.” In 2022, a UK parliamentary report on Baby Loss and Maternity Safe Staffing concluded: “The evidence that we have collected in this report paints a bleak picture of maternity and neonatal services that are understaffed, overstretched and letting down women, families and maternity staff, alike. […] For many, crisis mode is now the norm.”

A changing profession

Many view the current crisis in midwifery as indicative of problems that run much deeper than either the short-staffing created by the pandemic or the recent NHS pay disputes, and that in fact go to the core of the profession itself. “I think the vast majority of midwives would agree that it has the potential to be an incredibly rewarding role,” says Hazard. “But there seems to be a real consensus across the board that this is not the job that it used to be. And not just in the quantity of work but also in the quality – or the nature – of it. Staffing is a big part of it, but I think it’s also generally the feeling of working in this huge industrial machine that are the maternity services: very high rates of intervention, fear of litigation, less time to be with women, and less ability to individualise care to each person.”

These are elements that come up in all interviews: that the practice has become more interventionist, with far higher rates of caesarean births and inductions than in the past. This has been accompanied by what many describe experiencing as a ‘medicalisation’ of the profession, with the word ‘machine’ popping up multiple times. Midwives also describe treating an increasing number of more potentially complicated pregnancies, with developments in medicine enabling a wider range of women to give birth, including older women and women with riskier medical conditions. An increased use of obstetrics can also mean additional resource pressures in terms of both labour and funding needs and an ensuing shift of maternity professionals away from birth centres to hospital labour wards, thus offering less flexibility for women regarding their birthing options. The UK parliamentary Safe Staffing report stated that “maternity and neonatal services require substantial and sustained investment”. It continued: “We are seeing midwife-led units and homebirth services close in order to pool staff in obstetric units. We are seeing women’s choices curtailed, and antenatal and postnatal services squeezed.” Or as King of the White Ribbon Alliance puts it: “When the system is under pressure, the first thing to go is community practice.”

The evolution of the territory in which midwives are operating can have very literal consequences for the day-to-day reality of their working life. Downe, cites, for example, an “increase in paperwork due to the demands of organisational reporting and accounting (for both internal and external purposes)” which has “resulted in less and less time for midwives to spend with women in labour and during birth.”

She continues: “The increasing fear of litigation in the maternity services has also increased the general sense that spending time on record-keeping is a critical activity for both midwives and doctors, since these records are the basis for defence if there is such a case.”

And in such a challenging role, those in the profession thus feel it even more sharply when they perceive their work as not being valued. “The government really hasn’t recognised us as having acute frontline responsibilities, and it has consistently underfunded the maternity services across the UK,” says Hazard. “Add to that the mass exodus of older midwives, and you really have a perfect storm. There is recognition that the NHS is struggling, but maternity is well past crisis point.”

Is there a gender dimension to this lack of recognition? Hazard thinks so: “Historically, midwifery has been a service provided generally by women and for women. There’s a perception that this is just a ‘soft’ or ‘nice’ part of the NHS, and that there’s a lot of hand-holding and cuddling. That’s just really not the case. There’s a real lack of understanding of what we do and how acute the service can be. And I think there is an element of sexism around that, definitely. And this issue of public perception has been quite problematic for us in terms of fighting for our fair pay and conditions.”

“No one does this for the money,” says junior midwife Heidi. “But when you see all your friends getting a decent salary and bonuses in corporate jobs…we are keeping people alive. A pay rise is essential if only because of the stress involved. I’m furious about it. I don’t know one person who wouldn’t strike. And if I could I’d be on the frontline – but who has the time?”

Like Heidi, Hazard has also seen a lot of her colleagues leave, either for less challenging positions or to quit midwifery entirely, along with many who took retirement the minute it was offered. “And I’ve thought about leaving as well,” she admits. “I’ve had a really tough time and I still don’t know if this is a sustainable career for me in the long term. I definitely can’t do it until I’m 67, the pensionable age – and I’m hearing that across the board from all of my colleagues. The foundational issues are so deep now that it just feels like the challenges are constant.”