At the heart of Britain’s maternity crisis is a paradox. While other parts of the NHS are increasingly swamped, with people getting older and sicker, this should not be the case for obstetrics. Birth rates are dropping. Meanwhile, the numbers of midwives and obstetrics doctors have been rising for years. So how does reduced demand and increased supply end up landing us in a staffing crunch?
There is no doubt that maternity services are in turmoil. Recent tragedies – including home births ending in deaths – illustrate the point. Nearly half of all maternity units were rated "requires improvement" or "inadequate" in 2022-24 inspections. Maternal mortality has risen, newborn outcomes lag behind those in most high-income European nations, and clinical negligence claims absorb £1.3bn annually.
All diagnoses of the NHS tend to involve the word "overstretched". A recent review of maternity services by the Care Quality Commission is no different. "As demand for maternity services continues to increase," the authors write, “the staffing levels need to keep pace with the changes to keep women and babies safe." The review finds a single midwife "caring for 13 mothers and babies" on one postnatal ward.
But there is a contradictory story that runs alongside this, which is that units are closing for lack of customers. One in six have shut in the past decade – 31 of 190 maternity units, some permanently and some for the long term. Earlier this year the unit at the Royal Free, in north London, closed, with the hospital citing a low birth rate. Areas of central London, along with Cambridge and Brighton and Hove, have among the lowest birth rates (Barking and Dagenham’s is among the highest). For England and Wales as a whole, numbers of births have dropped – from 729,674 in 2012 to 594,677 in 2024.
Meanwhile the number of midwives in the NHS hit the highest level on record in February 2025, and has been increasing for at least a decade; there are around 2,000 extra posts since 2021. In the same time period, the numbers of obstetric consultants and maternity support workers have each increased, by about 400. So why does care keep getting worse?
Britain mainly gives birth on the NHS, with only around 0.4% of mothers using private maternity units. For the rest, there are some 155 hospital obstetrics units scattered across 120 NHS trusts, as well as birth centres run by midwives, some in hospitals and some free-standing; these latter tend to be recommended for women with lower-risk pregnancies.
One reason for staffing problems is that births are getting increasingly complicated, which demands more care by a greater number of nurses and doctors. That is mainly because pregnant women are now older, which raises the risks, especially for first pregnancies, which are the most dangerous anyway.
This combines with increased standards, which is undoubtedly a good thing but adds further to the strain. New studies have found that inducing labour can help reduce some problems brought on by later pregnancies, and meanwhile a set of new consent rules requires doctors to discuss all risks and possible solutions with patients. All this has meant that more mothers end up asking for inductions, which have risen from 23% in 2012-13 to 33% in 2022-23
“The huge increase in inductions has led to units which are struggling to cope," says Andrew Weeks, professor of International Maternal Health at the University of Liverpool. "In my own delivery suite, in Liverpool, we have a midwifery unit for women with straightforward births, but that’s increasingly being left empty. We’ve ended up converting half of it into an induction unit.”
Women also now have increased choice over how they give birth. That's a vital step in improving maternity care, but numbers of staff have not risen to cope with all the new options and choices, some of which are more risky than others. For example, a rise in "free-birthing" trends – often influenced by misinformation online – has meant an increase in complicated births at home. "Now we have women with twins, or previous cesarean sections, giving birth at home," says Weeks. Emergency admission to hospital is sometimes the result.
"The example I give is.. if you’re in an aeroplane taking off, and instead of asking everyone to put their seatbelts on you give them each a risk assessment on what would happen if they choose to stand up instead, or swap seats – and some take those options,” says Weeks. “Consent and autonomy are huge time consuming. You need to fund it and have a huge number of extra staff."
A vicious cycle may be under way, too. Increased awareness about stretched staff, bad birth experiences and tragic cases means many women now travel to avoid low-rated maternity units in their area. As The Observer reported earlier this month, this has led to "significant and unanticipated increases in demand" at some of the better-rated ones. In the summer, east London’s Homerton healthcare foundation trust said it was temporarily capping new maternity bookings owing to a "steady rise in out-of-area maternity bookings, which now make up 40% of our total births".
Another problem may be one of culture. Unlike most of the rest of the NHS, maternity units are not dealing with illness but with a natural process. It may be that this leads ideology to take over from evidence. Decades of "natural birth" orthodoxy have prioritised vaginal birth over cesarean sections, sometimes with catastrophic consequences. Leeds teaching hospitals trust is under investigation for a rising number of stillbirths and newborn deaths in the decade to 2023, which became the worst figures nationally. Like Nottingham, Shrewsbury & Telford, East Kent and Morecambe Bay, which are also the subject of scandals, it had a "philosophy of promoting 'normal birth'". In practice, that means midwives and doctors waiting too long to intervene in labour.
Clearly, hospitals should drop these philosophies, as should training programmes. A recent investigation found that two-thirds of universities promote "normality" in their midwifery courses, some "even in complex cases". No doubt Baroness Amos’s inquiry into maternity standards will make this recommendation; we will hear the first findings next month. But the second prescription is simply to spend more money. There may be fewer births, but they are more labour intensive. Staff numbers must catch up.
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