"One of the things my matron keeps saying is, 'We prepared for this last March and it didn't happen.' And now it's happening," Anna says. "This is what we expected to happen last year."
Anna has worked every weekend for the past three months and says her team is so short-staffed that it’s at risk of being dissolved. Two members of staff have left recently, one of whom was only 24, two years into her career and suffering badly from anxiety (she left to become a health visitor).
Anna had three months off work in 2019 for stress and says that mental health is a running joke among her colleagues. "I know it’s not funny but we joke about how they should hand out citalopram [a type of antidepressant] when you qualify," she says.
The pressure on Anna and her colleagues means that burnout is an ever-present danger, particularly for midwives experiencing bereavement, financial or family and relationship problems. "The level of stress I get from my job means that if anything in my life is a little bit out of kilter, I can't cope."
When midwives are stressed, burned out or unable to work, the pregnant people they work with may not get the support they want and need. Maternity services in Essex, Kent, Shropshire and Perth have all sounded the alarm recently over local staffing shortages. Across the country, birthing centres and maternity units have been forced to close temporarily because of staffing shortages (most recently in Oxfordshire and south Wales), and home births have been suspended in several areas in the past year, including London.
I know it's not funny but we joke about how they should hand out citalopram when you qualify.
A lack of midwives limits the care and choice available to pregnant people and at the very worst makes services unsafe. Last winter a survey by the Royal College of Midwives found that eight in 10 midwives felt that the service they worked for did not have enough staff to run safely, and last year the Care Quality Commission ruled that two fifths of NHS maternity units needed to improve their safety.
Earlier this year NHS maternity services were handed a £96 million boost, £46m of which will be used to recruit midwives. But for those in the sector, this funding has arrived way too late and significant numbers of midwives are leaving the profession. The UK’s 49,400 midwives were hit hard by the ‘pingdemic’ and rising COVID-19 infections – a large number of people in the profession have school-age children and were forced to take time off work to self-isolate or care for their kids. (In 2019 the NHS was short by an estimated 2,500 full-time midwives, at least, and new data shows that 300 midwives have left the profession in the last two months.)
Now, as children return to school and immunity wanes among frontline healthcare workers who were double-jabbed in spring, staffing shortages are likely to cut maternity services even deeper.
"I’ve only been a midwife for eight years and when I came into midwifery it was already short-staffed, so I was used to the pressure," Anna explains. "When the pandemic first hit, it wasn’t too bad. Now everything is really bad, more because of staffing than anything else."
Anna loves working for the NHS and stays upbeat despite the challenges. "Even on my worst days, I just say to myself, 'Get a grip, you're doing a job that you love, even though you're doing it in circumstances that are less than appealing'," she says, adding that even if she left midwifery she would stay in the NHS. But she has already thought about – and decided – what she’ll do if midwifery becomes "an untenable career".
Midwives in training are well aware of the pressures they’ll face. Hannah Paul, 28, is in her second year of a three-year course and now feels pessimistic about the profession she’s training for.
"Understaffing and burnout definitely has a knock-on effect on student midwives," she explains. "It’s hard [for them] hearing the stories of demoralised staff leaving the profession because they can’t provide the level of care they want to when they’re stretched so thin."
Life is no easier for independent midwives. Their work disappeared overnight last year after they lost access to professional insurance. The change left them unable to support women whose home births were cancelled by the NHS, effectively forcing anyone who went ahead into an 'unattended' birth.
One independent midwife, Jane Ashwell-Carter, 47, says she was forced to take a non-midwifery job, despite ongoing demand for her skills. "I am contacted two or three times a week by desperate women who have had their birth plans pulled from under them by staff shortages and withdrawn services," she says. "We stand on the sidelines, unable to assist for legal insurance reasons. How is this right?"
Midwives are at greater risk of problematic substance use than doctors or paramedics, and with less support.
Pressures have taken their toll on the profession. Next week Dr Sally Pezaro, a panellist for the Nursing and Midwifery Council (NMC), will publish a groundbreaking study on midwifery mental health in the journal Occupational Medicine. The first of its kind, the study shows that midwives are at greater risk of problematic substance use than doctors or paramedics, and with less support. Some 16% of referrals to the NMC (2014-16) relate to alcohol abuse. But by the time cases get referred to the NMC, people are at crisis point. These cases are just the tip of the iceberg.
"Midwives who experience problematic substance use currently have no access to confidential support for drug and alcohol addiction and face an impossible choice: seek help and risk being struck off, or struggle on alone," Dr Pezaro explains. New research into how and why midwives use drugs and alcohol is essential for developing pathways to prevent or address problematic substance use, she says. "The NHS can’t afford to lose midwives to drug and alcohol addiction, which is why this research is urgently needed."
"Doctors and nurses naturally anticipate they will face sick patients, trauma, ill health and medical issues in their work," Dr Pezaro says. "As the role of a midwife is to provide care to people experiencing childbearing, a physiological rather than medical event, they may anticipate such things much less. That is not to say that medical intervention is not expected when complications arise, but their less predictable nature may have unique implications for midwives’ wellbeing."
If the midwifery crisis persists, we are likely to see women’s already patchy access to elective Caesareans and home births diminish, and safety standards fall. This latter risk is particularly relevant to Black and South Asian parents: the Health Select Committee last summer highlighted evidence that Black women in particular are five times more likely than white women to die in childbirth.
But training more midwives will be pointless while the same stressors and poor pay await them when they qualify, unions warn.
"Not only have midwives faced a higher risk from COVID-19 but maternity services are stretched thin by staff shortages, leading to huge workloads," says Frances O’Grady, general secretary of the Trades Union Congress (TUC). "For most of the last decade, midwives had their pay frozen or capped. Their annual pay today is worth £2,000 less than a decade ago. This is no way to treat valued key workers – they deserve a real pay rise now."
Women’s advocacy organisations such as Make Birth Better campaigned against birth trauma during the pandemic. In January they published a survey which found that a third of maternity staff had no emotional support. Evelien Docherty, Make Birth Better's interim CEO, says: "Significant support needs to be put in place to ensure the mental health of our carers."
Ultimately, Docherty says, addressing the midwifery crisis benefits us all. "This is not just relevant to staff," she says. "We can never meet the needs of women and birthing people if staff aren’t supported sufficiently."
For those who experience it, pregnancy is one of life’s defining moments. In a world where our contraception is under-studied, our symptoms disbelieved and our fertility worries capitalised upon, we long for our pregnancies and babies to be safe and well-supported. Even if we don’t have or want to have children ourselves, change needs to happen for the benefit of our partners, friends and families.
The bottom line? Midwives need a fully funded, confidential practitioner health service – and a pay rise – ASAP, for everyone’s sake.
*Name has been changed to protect identity