Where are the midwives?

“There are many occasions when there are not enough midwives on shift”^[1]– What does this mean for pregnant women?

I recently had the opportunity to discuss the concerning reports in the press about the number of midwives leaving the NHS due to being overworked, undervalued and underpaid, with a lecturer in midwifery and medico-legal expert who I work closely with in my role as a child brain injury solicitor.

She told me there are many occasions when there are not enough midwives on shift. The aim of this blog is to explore what this means for pregnant women.

The potentially devastating impact that a lack of midwives providing antenatal, intrapartum and postnatal care can have on a labouring mother and her baby is particularly clear to me because of my work as a child brain injury solicitor. I specialise in compensation claims for children who have suffered brain injury. Many of my clients have sadly suffered brain injury at birth or at some point during the labour process. In my experience, understaffing of midwives increases the risks of inadequate monitoring of women in labour. This increases the risk of signs being missed that a baby is in distress, due to lack of oxygen for example, which in turn leads to delays in delivering the baby. A baby deprived of oxygen is at risk of suffering devastating brain injuries and in some cases, death.

An NHS desperately short of midwives

Official figures show that there are more unfilled midwife posts than ever recorded.^[2] NHS Digital’s quarterly update, which details vacancy rates for a range of health professionals, showed that the number of unfilled advertised nursing and midwifery posts in England reached 34,260 in the three months to September 2017. This is the highest level since records began^[3].

The NHS is seeing more nursing staff leave than join for the first time in history. Statistics show that during 2016-2017 just short of 33,500 nurses left the industry – this is 3,000 more than the number who joined and 20% higher than the number who quit in 2012-13^[4]. These are some worrying statistics because of the impact that a shortage on staff can have on labouring mothers and their babies.

Why is there a shortage of midwives?

The level of pressure on doctors and nurses who work for the NHS is undeniable. Budget restraints lead to salaries that in my view do not reflect the pressures of the role. Staff, such as midwives, are relied upon to work out of their goodwill and love of the job. I can quite understand why fewer people want to become midwives if they are expected to work long hours without a salary that adequately reflects the hours and the demands of the role.

Jon Skewes, The Royal College of Midwives (RCM) director of employment relations, policy and communications comments that:

“Maternity services continue to rely on the goodwill of midwives and the RCM has warned time and time again that is unsustainable. The impact that seven years of pay restraint has had on employment relations between midwives, MSW’s and the NHS is now hanging by a thread. It is a completely untenable situation which cannot continue. In 2017 the value of pay for a midwife at the top of band six has decreased by over £6,600 since 2010.” ^[5]

Risks to pregnant women

The impact of a lack of midwives is obvious; there will be a knock on effect in terms of the standard of care provided to pregnant women. Jon Skewes said: “The NHS in England remains 3500 midwives short of the number of midwives it needs to deliver a safe and high-quality maternity service.”^[6]

The midwifery expert observed that when there is a shortage of midwives within the labour ward, antenatal, postnatal or community midwives will be called in to help. In my view this must have an obvious knock-on effect on these other areas which means that women might not receive an adequate standard of care. She further commented that if labour wards are short staffed then women in labour are sometimes sent further afield to give birth. This concerns me because if a labouring woman has to travel to give birth and the labour accelerates more quickly than anticipated, or she encounters difficulties; there is a risk of the baby becoming distressed, hypoxic or the mother giving birth en route to the hospital without the medical support she or her baby require.

Our midwifery expert reassured me that it is only in very rare cases that a woman is denied one-to-one care during labour; however, in my view there should never be an instance where a labouring woman is without one-to-one care because this can lead to inadequate monitoring.

Our midwifery expert further commented to me that sometimes “case loading” takes place whereby a pregnant woman will have contact with a small group of midwives throughout her pregnancy. The aim is for the women to have access to the same two midwives all the way the way through her pregnancy. This ensures continuity of care throughout the antenatal, intrapartum and postnatal periods which is vital. She says this is an excellent service but sadly this is not common practice. Continuity of care is important because women need to feel confident going into labour; it helps if they have built up a relationship with their midwives.

In my role as a medical negligence solicitor specialising in child brain injury, it is apparent to me that a lack of midwives can result in the following consequences:

A lack in emotional support for pregnant women
Failure to adequately review maternity records including antenatal and screening history
Failure to adequately monitor and record the fetal heart rate (including failure to act upon a suspicious or pathological CTG trace)
Avoidable delay in summoning a registrar or obstetrician to assist when signs of fetal distress are noted
Failure to record adequate contemporaneous notes
Delay in transferring a patient to the labour ward and sometimes a delay in delivering a baby
Failure to carry out ‘Fresh Eyes’ assessments during labour (whereby a second midwife confirms the fetal heart rate pattern every hour, reducing interpretation errors)

Advice to parents

I have considered what pregnant and labouring women can do to ensure they receive the best care possible and reduce the risks of injury to themselves or their babies.

I would advise women in labour to:

If possible, have an advocate with you to communicate with staff (particularly as when in labour you may struggle to communicate clearly)
Stay calm
Be assertive and communicative with hospital staff about your concerns
Escalate concerns to the lead midwife or consultant obstetrician
Provide as much information as possible regarding your presentation and symptoms

Our midwifery expert recommends:

Have conversations with community midwives early on (during the antenatal period) to have an understanding of what goes on throughout labour/delivery
Do not give up human rights at the door; ensure an understanding of all decisions made and ask for better explanations if there is any uncertainty as to what is going on
Consider the type of care required not just in labour but throughout the antenatal and postnatal period too
Read advice from reputable sources and have discussions with trusted friends and family members

After you have given birth, if you remain unsatisfied with the treatment provided you can:

Write a letter of complaint to the chief executive of the hospital in question. Thereafter the hospital should carry out an internal investigation into the events so that staff can learn from their experiences.
Contact the Patient Advice and Liaison Service (PALS) who offer confidential advice, support and information on health-related matters. Officers from PALS can be found within hospitals.
Consider professional support, including legal advice, which can help assess the care and needs, which both mother and baby could be entitled to and whether there is compensation available

Litigation following failings in midwifery care

If midwifery care continues to be inadequately resourced by the NHS, I anticipate there will be a growing number of medical negligence claims due to birth injury leading to substantial awards of damages.

At Bolt Burdon Kemp our child brain injury team are dedicated to investigating claims where you feel substandard medical treatment has caused your child to suffer a brain injury.

Claudia Hillemand is a senior associate in the Child Brain Injury team at Bolt Burdon Kemp. If you have a claim on behalf of a brain-injured child, contact Claudia free of charge and in confidence on 020 7288 4843 or at claudiahillemand@boltburdonkemp.co.uk. Alternatively, complete this form and one of the solicitors in the Child Brain Injury team will contact you. Find out more about the Child Brain Injury team.

^[1] Lecturer in midwifery and medico-legal expert

^[2] https://www.theguardian.com/society/2018/jan/23/nhs-england-recruitment-crisis-nursing-vacancies

^[3] https://www.theguardian.com/society/2018/jan/23/nhs-england-recruitment-crisis-nursing-vacancies

^[4] https://www.theguardian.com/society/2018/jan/23/nhs-england-recruitment-crisis-nursing-vacancies

^[5] https://www.rcm.org.uk/news-views-and-analysis/news/%E2%80%98maternity-services-can-no-longer-run-on-goodwill-of-midwives-says-rcm%E2%80%99

^[6] https://www.rcm.org.uk/news-views-and-analysis/news/%E2%80%98eliminate-the-midwifery-shortage%E2%80%99