The Eco Midwife

UK maternity services are under pressure, with increasing amounts of recommendations, reports and reviews without addressing the elephant in the room of staffing to be able to provide the basic level of needs of families in maternity services. There is an ongoing investigation into maternity services by Baroness Amos, however it is imperitive that midwife and student midwife voices are amplified to be included in the challenges we face everyday.

The amazing Leah Hazard is campaigning to to establish legal limitis ofn midwife working hours – please sign the campaign here: https://www.change.org/p/establish-legal-limits-on-midwives-working-hours

This below is a template to use for writing to your own MP. Please feel free to adapt and include your own experiences as a midwife. The only way change will happen is if enough of us amplify our voices to those with the power to make recommendations and actions.

How to write to your MP: https://www.parliament.uk/get-involved/contact-an-mp-or-lord/contact-your-mp/

You can also attend clinics to discuss further – again writing to them will enable you to book time to discuss.

Dear

I am writing to you regarding the current ongoing maternity investigation and to put forward my concerns regarding maternity services as a midwife and also provide solutions in the hope these will reach Baroness Amos for consideration as a midwife who works on the front line.

Key Points/Recommendations from a frontline midwife which will have the biggest impact on outcomes, experience and safety for families:

To include babies on postnatal wards in patient numbers – currently all trusts do not include a baby as a patient.
Have maximum number of inductions of labour a midwife can provide care to at any one stage
Provide guidance on registered to unregistered staff numbers for all areas.
Begin collecting number of triage, assessment and inpatient admission data to guide staffing ratios required
Provide guidance on community midwifery caseload numbers
When staffing workforce numbers cannot be achieved due to unavailability (sickness) then temporary staffing or agency must be used to cover the service or pause planned activity
Skill mix recommendations for attending home births
The return of antenatal education programmes for all pregnant women, people and families

Background

Whilst staffing ratios are down to local trusts, highlighting significant variation across the country, further guidance and evidence based advice is provided by NICE, royal colleges and overseen and regulated by the care quality commission (CQC). Outside of intrapartum care, there are currently no minimum safe staffing ratios recommended for community midwife caseload numbers, maternity wards, maternity assessment or triage services to provide safe care. Many trusts use acuity apps and tools such as birthrate plus to obtain overall recommended midwifery workforce establishment numbers, however it does not capture number of unexpected admissions during pregnancy, number of assessment unit admissions, nor number of inpatient visits or readmissions, nor does it capture the length of stay postnatally.

With the rising complexity of childbirth in the UK, evidenced by a 40% induction of labour rate and a 50% caesarean birth rate, the demand for care has surged significantly over the last three years. Medicalisation is increasing in maternity services with national papers such as saving babies lives recommending more reasons to advise an induction of labour. More medicalisation leads to higher readmission rates postnatally, and higher complexities in future pregnancies. As seen in the MBRRACE (2025) mortality data, maternal mortality is increasing alongside increasing medicalisation. Women who are most deprived or who are racialised as black of brown are most like to be impacted by higher mortality rates – an inequality which needs addressing.

Over the last decade, midwives have been expected to deliver more with less resource. Each year there are more and more tasks, more risk assessments, more expectations to implement more. At no point have time in motion studies been undertaken in community, assessment or triage units to understand the sheer workload placed upon midwives to ensure each contact with families meets the needs and safety they deserve. The birthrate plus ward acuity tool is not used in antenatal and postnatal wards everywhere, and what is staggering is from an FOI of trusts when it is used, it highlights a significant proportion of time being in the red – highlighting there are not enough members of staff to provide the care required from women. This deficit leads to unsafe clinical situations for women, people and their families as the basic level of care required cannot be met. Increasing complexities and medicalisation means in reality more staff are required. This leads to high burnout, increasing demand on primary care services with mental health, increasing pressure for midwives to work excessive hours and in turn a huge turnover in staff – 8-10% of newly qualified midwives leave within the first year due to the extreme pressures they work under. 700 midwives are now leaving the NMC register every 6 months highlighting the retention crisis which is before us.

Whilst units are required to implement their own local staffing models, it requires national guidance in order to implement this and also to provide the solid and hard evidence to hold maternity trusts accountable to meet those thresholds. There is no national guidance at present. In addition the only place where there is a recommendation is in labour wards with one to one care, meaning staff are redeployed from other areas to cover labour ward recommendations – placing more pressure on other areas of maternity and reducing number of care hours to meet recommended levels.

Key recommendations:

Counting babies as patients

Babies are not counted in any patient ratio on postnatal wards. The Royal College of Nursing recommends a minimum ratio of one staff member to eight patients on adult wards, with smaller ratios suggested for more high dependency/ intensive care. The British association of perinatal medicine recommends a ratio of 1 nurse to 4 babies on transitional care units. Transitional care is an area providing additional observations and monitoring to babies born under 36 weeks or those where intravenous antibiotics are given for suspected or confirmed infection. Sadly there is a large proportion of babies who require additional monitoring such as blood sugar monitoring (with increasing maternal diabetes and pre eclampsia this rate requiring blood sugars has soared), or observations for suspected infections (requiring 2 hourly baby observations) who do not fulfil this staffing ratio model in transitional care, yet are needing a significantly higher amount of care. [Insert any experiences here for your local trust].

Induction of labour ratios:

In addition, there are no recommended staffing ratios for women and people having an induction of labour. This is placing women at risk, and having a huge impact on them feeling listened to and having appropriate care. The latest birth trauma report underscores the urgent need for appropriate care, meaning that many women are labouring without adequate support and many are left alone during inductions – particularly on wards. [Insert any experiences here for your local trust]. This can lead to women feeling alone, unsupported and without adequate pain relief. Realistically speaking, how can any midwife provide adequate care to 6-8 women commencing labour and provide safe monitoring to them and their babies? Whilst the SITREP from NHS England is monitoring any escalation in trusts on a daily basis now, it does not provide any guidance nor support in how to increase workforce numbers to be able to provide care in high acuity.

Provide guidance on registered to unregistered staff numbers for all areas.

Currently birthrate plus work on a ratio of 90% registered staff to 10% unregistered staff as part of establishment, however there is no detail on how this skill mix should be deployed. This needs national guidance to guide trusts. In addition, maternity support worker retention is becoming increasingly difficult with the rising expectations and responsibilities they are expected to achieve. Due to minimum wage increases, there is little to no financial incentive to work in the NHS as a maternity support worker compared to other minimum wage jobs. This needs to be a priority with uplifts in pay implemented. [Insert any experiences here for your local trust].

Begin collecting number of triage, assessment and inpatient admission data to guide staffing ratios required

Currently triage, assessment and inpatient admissions do not guide the overall establishment numbers required in birthrate plus nor other acuity apps. In addition, this financial data for care provided during assessments is also not captured (and due to the payments in maternity services this is a block payment which does not provide payment for in-patient care nor additional assessments required outside of ‘standard care’). Assessments have sky-rocketed with increasing awareness of fetal movements and other pregnancy complication symptoms over the past ten years to enable early assessments and interventions, yet the infrastructure has not been there to support the demand, nor has it been monitored or assessed or captured nationally anywhere. This needs urgent review to enable safe care and timely responses in maternity services. Maternity triage has started to be monitored from CQC experience surveys, and this highlights the challenges being reported by women themselves. [Insert any experiences here for your local trust].

Provide guidance on community midwifery caseload numbers

Currently there are no caseload ratios recommended, with increasing complexity, maternal mental health and anxiety particularly surrounding concerns relating to maternity services, demand is high for community midwifery appointments. In addition on calls required by community midwifery teams can leave services short when midwives are called out to provide home birth care, which places additional pressure on existing workforce. This increases the rate of burn out and stress, higher sickness and absence which is highlighted in the Dharzi (2024) Independent investigation of the national health service in England. In addition, many home birth services are suspended when community workforce numbers are reduced. This reduces access of care for women, reduces choice, and increases the number of people needing to access acute maternity services – placing more pressure on inpatient services. Home birth services are not prioritised nationally instead, the 1-2-1 acute unit intrapartum staffing to patient ratios are. Until all areas of maternity have safe minimum staffing ratios to meet, women are going to continue to be impacted.

When staffing workforce numbers cannot be achieved due to unavailability (sickness) then temporary staffing or agency must be used to cover the service or pause planned activity

When workforce numbers scheduled or rostered to meet care needs of women are not possible due to sickness and absence, this has a huge impact on safety to be able to meet the care needs of women and people. In not having enough staff on shift, there are less physical care hours available. This increases the amount of errors, it increases the number of staff not having breaks which contributes to high stress levels, and women not receiving the care they require. Many trusts will use temporary staffing, or have someone to be able to call round and ask people to swap shifts to cover absences. Not many trusts use midwifery agency due to the cost of agency.

Often shifts are left short staffed to their current ratios because the gaps are not able to be covered. There is no national guidance on pausing planned activity in maternity services, delaying planned caesarean births or inductions of labour meaning it is down to trust level to decide this. With so many trusts fearful of litigation of those who are to be delayed, more often than not planned activity continues which means midwives provide care for even more people and are stretched even more thinly. They then miss breaks to cover the demand or because they are unable to be relieved for a break (nobody to cover their 1-2-1 care), which impact on their health and wellbeing and leads to increased sickness within services. This is against working time directives, but staff at all levels are placed in impossible situations to provide the care women, people and families deserve.

Skill mix recommendations for attending home births

The skill mix of midwives attending home births requires review. There is significant variation across the country in who attends home births, and the skill mix. As seen in Jennifer Cahills sad death, the midwives providing care were awake for over 30 hours providing care, and as heard in the inquest intrapartum care is the smallest part of a community midwife job role. It is imperative with increasing complexity and request for ‘out of guidance’ home births that increasing the intrapartum skills of those providing home births improves and increases. Some areas have dedicated home birth teams who maintain intrapartum midwifery skills, but another option is for home births to be attended by an intrapartum core midwife and a community midwife, providing the ultimate dream team of community home based expertise and high risk intrapartum expertise, to share knowledge, skills and provide all the skills required to meet the needs of women. This again requires national guidance and recommendations for trusts to be held account.

The return of antenatal education programmes for all pregnant women, people and families

One of the increasing challenges in time given increasing medicalisation. Ten years ago, antenatal education programmes were offered to all pregnant women and there was time dedicated for antenatal, intrapartum and postnatal/parenting information. This included key public health messages. There is large variation in what and how many hours is provided to antenatal education. When women then enter maternity units, there is a myriad of questions asked where they have not been provided with this information or education ahead of time. This demand increases the time women and people need with midwives and adds additional pressure. This is another aspect which requires national guidance and framework to again hold trusts accountable for delivery and to meet the needs of local populations in a range of formats and options such as digital, in person and with the ability to translate for those where English is not the first language. There are some incredible antenatal education initiatives too which can be seen to reach black and brown communities such as black mothers matter which can be replicated across the country to improve access and equity in antenatal education.

To conclude

Midwives have been shouting for better infrastructure and support to meet the needs of women, people and their families for years. The biggest resource to meet the basic needs of both service users and midwives is staffing hours and staffing numbers. Without midwives, no maternity care or service can be provided. Without midwives, birth trauma, poor experiences with maternity services and increased mortality will continue. There can be hundreds of recommendations or initiatives to try and improve care for women (all of which will likely further increase midwifery workloads and tasks), but unless the fundamental basic principle of staffing is addressed at national evidence based and recommendation level, trusts will not be held accountable nor do they have any recommendations to implement the levels of staffing required to provide safe care. It is imperative for national recommendations on staffing in all areas of maternity care, and for babies to be classed as patients to be implemented as a matter of urgency especially as complexity and demand for care increases.

I look forward to your response on this matter.

Yours sincerely