Maternity At Breaking Point!

Lively contingent of midwives and their families on the TUC demonstration in October last year
Lively contingent of midwives and their families on the TUC demonstration in October last year

MATERNITY services are overworked, understaffed and struggling to cope, a senior midwives survey shows.

Maternity unit closures, budget and training cuts and reduced services are among the issues highlighted by a survey of UK senior midwives published by the Royal College of Midwives (RCM). The RCM believes that maternity units are facing unprecedented challenges as a historically high birth-rate, increasingly complex births, and a serious shortage of midwives in England piles pressure on services.

According to the survey of Heads of Midwifery (HoMs) over two-fifths of maternity units had to close during the last year because they couldn’t cope with the demand – 32.8% in 2014 and 41.5% in 2015. Units closed their doors on average on 6.6 separate occasions in 2014 and 4.8 separate occasions in 2015. The most times a single unit closed in a year was 33 times (2014) and 23 times (2015).

The number of closures is a reflection of the rising demands on services from increasingly complex births and staffing levels. Most senior midwives surveyed, 96.9% in 2014 and 91.3% in 2015, said their unit is dealing with more complex cases than the previous year. On staffing levels well over a quarter of HoMs, 29.5% in 2014 and 29.6% in 2015, said that they simply did not have enough midwives. The shortage of midwives in England remains critical with the country still short of 2600 full-time midwives.

Services are also being reduced as inadequate funding and staffing shortages bite. A tenth of HoMs, 10.9% in 2014 and 11.0% 2015, reported that they had to reduce services in the last year. This included reductions in specialist midwives, fewer parent classes and less bereavement and breast feeding support.

Services such as home births and postnatal care are also suffering. Around two-thirds, 65.6% in 2014 and 64.6% in 2015, of HOMs said that on-call community staff have to be called in to cover the labour and delivery suites. In 2015 a third of HoMs (35.8%) said that this restricted the home birth service, up from just over a quarter (26.2%) in 2014.

In both years HoMs overwhelmingly reported that the most common type of redeployment was staff from the community and postnatal service to the Labour and Delivery Suite. This is a real concern for the RCM, as this restricts choice for women and affects the quality of care that women and their babies receive.

A lack of adequate care in the postnatal period can affect breastfeeding rates through lack of postnatal support. It also makes spotting infection in the mother or baby or maternal mental health problems less likely. This can have potentially disastrous consequences. This redeployment is also happening far too often. In both years three-quarters of those surveyed said they had to redeploy staff to cover essential services either very or fairly often.

HoMs were also concerned about how maternity services were valued by their organisation’s board. In the 2015 survey almost a fifth (19.2%) of HOMs disagreed or strongly disagreed with the statement ‘maternity is a priority in my organisation’. Many HoMs responding to the 2015 survey also had concerns about how well they were able to do their job given the pressures and demands of the role.

Nearly a third (31.2%) disagreed or strongly disagreed with the statement ‘I am able to do my job to a standard I am personally happy with’. It is also worrying that nearly two-thirds (62.3%) in 2015 disagreed or strongly disagreed with the statement ‘I am able to meet all the conflicting demands on my time at work’. Some HoMs also reported having to provide additional midwifery services but without any extra budget. The RCM of course welcomes additional services but they must be adequately funded.

Major reports including the Francis and Kirkup Reports have focused on the importance of staff training. It is a concern then that two-fifths, 21.9% in 2014 and 20.3% in 2015, of HOMs had to reduce training for their staff. Training and continuing professional development are critical to ensure staff can deliver safe and high quality care.

Commenting on the survey, Cathy Warwick, chief executive of the Royal College of Midwives, said: ‘Midwives and maternity support workers are too often keeping services afloat by working long hours, often doing unpaid overtime and missing breaks. This is not a situation that leads to safe and high quality care for women and babies.

‘All of this shows a system that is creaking at the seams and only able to deliver high quality care through the efforts and dedication of its staff. When services are operating at or beyond their capacity, safety is compromised and mistakes can, and almost certainly will be made, through no fault of the dedicated staff delivering the service. The government is responsible for this and it is they who are letting down women, babies and their families, as well as the staff they purport to value. This is simply not acceptable.’

The surveys of Heads of Midwifery form part of the RCM’s submission to the NHS Pay Review Body 2015. Sample survey comments from Heads of Midwifery include:

‘Staffing is and will remain a safety issue and financial pressure. The level of pressure everyone is feeling is now palpable. Worrying times. All staff including non clinical based roles are under extreme pressure with many of us working c.60 hours per week on 37.5 hours contracts for no additional pay and still not keeping up. When struggling, the response from the top floor is to delegate; to whom I ask? Everyone is too busy.’

‘I am very concerned about the state of the NHS. How is it possible to continue providing high levels of individualised quality care year on year with high cost reductions, cuts to training budgets and more women with complex needs? Stress in the workplace directly affects women’s care. The pressure all grades of staff are experiencing is palpable. As a head of service I feel powerless to affect change. . . Staff who do not have time to train, develop professionally and do not feel valued will struggle to provide safe, high quality compassionate care. . . . The impact on the staff providing the service with the endless financial, physical, emotional and professional challenges is deeply concerning.’

‘Excessive activity and workload for staff. 12 hour shift patterns impact on break cover so staff have to stay late to do any emails, closure report information, student assessments etc. Activity can be high at times and breaks are missed or not completed. . .these unpaid breaks cannot be compensated for.’

‘The maternity tariff does not appear to take into consideration some of the complexities which require additional care and time to provide an effective service to the woman and baby e.g. mental health issues only equate to an intermediate tariff. Midwives have to work as flexibly as possible – on call working overnight and call outs impact on routine daily workload. Clinics/appointments may need to be rescheduled if midwives require compensatory rest if they have been working overnight. This adds pressure on the rest of the team for that day and midwives miss lunch, work over hours and service user appointments have to be cancelled or rescheduled.’

‘I feel staff are feeling the pressure of austerity with the major drive to bring down costs within the NHS. The continued pressure of adding services to the midwives portfolio without extra funding, because the service is apparently in tariff, this is not sustainable. The current trust focus is on the financial pressures being faced which proves to be a constant challenge when the quality and safety of care to women and babies cannot be compromised.’

‘I have been a HoM for less that one year and I struggle with a tiny management structure and being able to articulate the differences and difficulties that midwifery faces as opposed to nursing. . . I work ridiculous hours to not even stand still. I am passionate about midwifery services but we need more support from the government.’