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Counting midwives

21 January, 2014

Counting midwives

Are estimates of the number of midwives needed to tackle the workforce shortage enough, or are there other factors that aren’t taken into account when calculating midwife ratios? Consultant midwife Monica Tolofari investigates the issue.
Midwives magazine: Issue 1 :: 2014

Are estimates of the number of midwives needed to tackle the workforce shortage enough, or are there other factors that aren’t taken into account when calculating midwife ratios? Consultant midwife Monica Tolofari investigates the issue.

More babies were born in England in 2012 than in any year since 1972, while births to women aged 30 and over were at their highest since 1946 and the number of pregnant women aged 40 years or more increased by 80% in a decade (RCM, 2013). While there is now evidence that the rapid increase in birth rate has started to tail off slightly (RCM, 2013), an increase in the midwifery workforce is still desperately needed to cope with demand.

In 2011, the RCM spearheaded a campaign calling on the government to recruit the equivalent of 5000 more full-time midwives (Warwick, 2011). The latest figures, contained in the State of maternity services report 2013 (RCM, 2013) estimate that, despite an increase in the number of midwives across England, the country still needs 4800 more.

Given that women are having children later in life and births are becoming more complex (RCM, 2013), it could be argued that the increase in midwife numbers is actually a gross underestimation of what is required to meet the needs of women in maternity services in England.

Until the Ball et al (2002) study Why do midwives leave?, the subject of shortages of midwives, their workload and job satisfaction appears to have been under-researched. And studies carried out in other countries are not comparable to the UK, due to fundamental differences in midwifery structures and the management of pregnancy and childbirth (Lu et al, 2007; Yin and Yang, 2002).

Calculating the number of practising midwives
Despite the NMC having a register of practising midwives, no one knows exactly how many are really on our shores. A practising midwife is someone who has qualified as such and is up to date with Prep standards (NMC, 2010). Annually, they register their intention to practise (ITP) with the local supervising authority of the area in which they wish to work, and pay their annual registration fees to the NMC. However, registering an ITP does not mean that midwives are actually working in practice every day (NMC, 2010), as they could be unemployed or working occasionally. They could be bank midwives, health visitors, nurses, teachers, lecturers, or have jobs in leadership, management or research. They could also be on sick or maternity leave. Therefore, the total number of midwives may be skewed by their presence on the register, giving a false impression of a full complement.

Currently, the number of live births is used as the yardstick for calculating the number of midwives needed in the workforce. But, with regards to maintaining quality and capacity and addressing the shortage of midwives, this live birth measure underestimates all other aspects of the midwife’s role and potentially fails to adequately assess the level of depletion.

Despite Birthrate Plus acknowledging best practice and the need to address complexity and models of care when devising workforce plans, many provider trusts have not adopted the recommended midwife-to-mother ratios, due to budgetary cuts.

The necessary calculations for how many midwives are needed are complicated. They take into consideration the population needs in terms of medical and social complexity, midwives’ cross-boundary practice (where they deliver antenatal and postnatal care for other hospitals), the student midwife ratio to qualified staff, daily skill mix, and the normal workload of midwives themselves, which should include their areas of expertise and levels of experience.

Midwives’ health
An independent review by the Audit Commission (2011) showed that sickness among midwives was highly likely to affect productivity at work, which is one of the main reasons why people leave the profession and is also linked to the majority working part time.
Midwives reported that it was not unusual to return to work before they had fully recovered from sickness, due to concern for their overstretched colleagues. Regularly missing meal breaks and finishing shifts late was the cultural norm and, as a daily occurrence, affected their resilience (Tolofari, 2011).

Working in this relentlessly pressured workplace raised concerns and questions around whether the health of the midwifery workforce was sufficiently promoted.

If midwives expressed a need, this was seen as weakness, as there was a culture of blame and guilt (Kirkham, 2007; Kirkham and Stapleton, 2000). Midwives felt pressured to conform in order to prevent themselves from being ostracised (Kirkham and Stapleton, 2000).
Unfortunately, this led to them feeling unable to voice their opinions or feelings (Johnston, 2004). They learned to be mute, because the culture was one of disempowerment (Johnston, 2004; Beech, 2000).

Research by the author (2011) examined staff turnover, job satisfaction and the reason why midwives left or stayed in their post. It showed that 77% (n=117) of midwives expressed concern about being overworked and maintaining a safe service for mothers and babies, while not a single midwife responded saying they were underworked (Tolofari, 2011).

Working lives
Midwives’ work is time-intensive because it takes effort and patience to promote health, support women in childbearing and with language difficulties. Giving birth is preceded by preconceptual and pregnancy care, and followed by care for their neonate and breastfeeding help and support. Midwives also care for pregnant women who are in mourning; women will have terminations, miscarriages and stillbirths, outcomes of which all carry a counselling load. However, the calculation of midwife ratios is based on live births and does not take into account miscarriages, terminations of pregnancy and stillbirths. These omissions can lead to a serious understatement of their actual workload.

The idea that maternity services and midwife numbers can be planned in light of only healthy live births clearly leads to faulty conclusions, while a rising population and an ageing midwifery workforce, with many set to soon retire, give added concern.

There is a lack of robust data and no reckoning of total pregnancies by which to plan either antenatal or postnatal care for those whose pregnancy does not end in a healthy live birth, including all miscarriages (estimated at 15% to 20% of all pregnancies up to the 23rd week) (Puscheck, 2013).

Midwife retention is not just about numbers of midwives. It is also about ensuring that accurate data on workloads are captured and meaningfully interpreted, so that adequate provision is secured. It is about ensuring that those who remain are being revitalised and enthused, not subdued into silence and drudgery.

There is a price to be paid for disinvestment in midwives, such as poor-quality services and litigation. Fully understanding what is required to deliver good maternity services, by NHS commissioners and contractors, could lead to funding that enables provider trusts to employ more midwives in their skill mix, to cope with the rising demand for maternity services.

Monica Tolofari
Freelance consultant midwife Maternity Action and former consultant midwife in public health at Heart of Birmingham Teaching PCT and Sandwell & West Birmingham Hospital Trust


Audit Commission. (2011) Managing sickness absence in the NHS. See: www.audit-commission.gov.uk/SiteCollectionDocuments/AuditCommissionReports/NationalStudies/20110210managingsicknessabsence.pdf  (accessed 14 January 2014).

Ball L, Curtis P, Kirkham M. (2002) Why do midwives leave? RCM: London.

Beech BL. (2000) A way forward for midwives. AIMS Journal 12(1): 12.

Johnston D. (2004) Why do midwives stay? Unpublished BSc dissertation. Birmingham City University: Birmingham.

Kirkham M. (2007) Traumatised midwives. AIMS Journal 19(1). See: www.aims.org.uk/Journal/Vol19No1/traumatisedMidwives.htm (accessed 14 January 2014).

Kirkham M, Stapleton H. (2000) Midwives’ support needs as childbirth changes. Journal of Advanced Nursing 32(2): 456-72.

Lu H, While AE, Barriball KL. (2007) A model of job satisfaction of nurses: a reflection of nurses’ working lives in Mainland China. Journal of Advanced Nursing 58(5): 468-79.
NMC. (2010) Staying on the register. See: www.nmc-uk.org/registration/staying-on-the-register/ (accessed 14 January 2014).
Puscheck EE. (2013) Early pregnancy loss. See: reference.medscape.com/article/266317-overview#aw2aab6b2b3 (accessed 14 January 2014).

RCM. (2013) State of maternity services report 2013. RCM: London. See: rcm.org.uk/college/policy-practice/government-policy/state-of-maternity-services/ (accessed 15 January 2014).

Tolofari M. (2011) Why do midwives leave their posts? The advanced practitioner’s role in reducing staff turnover and determining job satisfaction. Masters dissertation. Birmingham City University Library, Birmingham.

Warwick C. (2011) Recruit 5000 more NHS midwives in England. See: epetitions.direct.gov.uk/petitions/13716 (accessed 14 January 2014).
Yin JC, Yang KP. (2002). Nursing turnover in Taiwan: a meta-analysis of related factors. International Journal of Nursing Studies 39(6): 573-81.

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