A toxic cocktail of staff shortages, excessive workloads, and unsupportive work cultures has resulted in record levels of burnout among midwives across the UK, The Lead can reveal. Our analysis of NHS data shows that since May 2020, midwives have had higher rates of stress and psychiatric related absence than all other clinical staff groups at any given time.
By compiling monthly releases of sickness absence records for the three years since February 2020, we found that the profession’s proportion of mental health and stress related sickness absence days averaged out at 30%. Within clinical roles, supporting staff had the second highest rate (26%), and doctors had a 21% average, lower than nurses (24%), and ambulance staff (25%).
The disparity between rates of psychiatric related absence for midwives and the wider NHS average has steadily increased over time, growing from just under +2 percentage points in February 2020, to +4 percentage points in February of this year. Last July, this saw rates for midwives rocket back up to mid-pandemic peaks while those for most other clinical staff groups remained well below the highs seen during the pandemic.
“A lot of people in our team are suffering mental health problems,” says Laura*, a midwife who works in a community unit in London. “It's not always the people you expect either, it’s younger midwives, who've only been working for a few years – and sometimes it's the older midwives who are coming up to retirement and worrying about whether they can afford to retire,” she adds. “It’s everyone. You feel like the service is hanging on by a thread.”
“The pandemic took a huge toll. There was absolutely no time for midwives to recover before we went straight into a staffing crisis,” explains Lynne Galvin, officer for North of England at the Royal College of Midwives (RCM) union.
“You feel like the service is hanging on by a thread.”
The phenomenon hasn’t gone unnoticed. Back in September, the RCM warned that burnout among midwives was “higher than ever’” More recently, its survey from March 2023 titled ‘Overworked and Underpaid’ revealed that nearly three quarters of midwives (64%) feel burnt out or exhausted at the end of all or most of their working shifts.
Galvin has seen this first-hand. “We are certainly seeing more and more midwives with mental health problems as a result of stresses in the workplace,” she says. The observations come amid reports that midwives give approximately 100,000 hours of free labour to the NHS each week in order to keep England’s maternity services safe.
“It’s been increasingly difficult for us, because we’re dealing with very anxious members, and members whose mental health is severely affected,” the RCM officer explains. It’s also a trend that spans demographics.
Inadequate staffing levels play a big role in incubating workplace stress and anxiety, and according to Laura, units frequently have to request assistance from other areas as a result of shortages. “Virtually every single shift that I work on, we have to use bank staff because we don’t have enough core staff,” she explains. But bank staff aren’t always available, and sometimes entire units are temporarily shut down. This echoes the ‘Overworked and Underpaid’ survey which found that 87% of midwives did not feel their workplace had safe staffing levels, up from 69% in 2020.
As a result, juggling shortages has become a workload in and of itself, on top of an already demanding job. “In the morning I’d like to come in, have a reasonable workload, and get on with it, but often because of shortages the beginning of the day usually involves a great deal of shuffling around, and the stress of trying to make sure everything’s covered,” Laura says.
It’s something that has a butterfly effect across the system. “We're not always delivering the service that we want to deliver because of constraints caused by staff problems, funding problems, and a lack of pay,” she adds. The impact on those being looked after is clear, and the Ockenden Review of Shropshire-based maternity units published last year investigated how 300 babies were left dead or brain damaged as a result of inadequate NHS care.
“Tall poppies often get cut down, because they're seen as a threat.”
Since then, the Care Quality Commission has started a national inspection programme, and out of the 45 units examined so far, almost half have been rated as substandard. At Poole hospital, the regulator found that a lack of staff and beds contributed to 170 delays to labour induction in six months alone, while at Birmingham Heartlands hospital, staff shortages contributed to four-hour waits in the pregnancy emergency room.
The trend also has direct psychological consequences for midwives. “It makes our job much more stressful, both in terms of trying to get through the work but also in terms of worrying that maybe you’re not going to have time to get around everyone,” Laura explains. The ramifications of working in a caring role but being constrained by systemic underfunding have impacted Galvin too. “We are trying our best to deliver really high quality care but when you’re on a shift and there’s too many women to look after it is so frustrating not to be able to give the care that you want to give, and it really does play on the minds of midwives.”
Last year, nine in 10 (88%) of the midwives surveyed in the RMC’s report had worked additional unpaid hours, up on 79% in 2020, and well above the national average for all NHS workers. According to the Nursing and Midwifery Council’s inaugural ‘Spotlight’ report published in August, managers also have “unrealistic expectations” about staff fulfilling duties outside scheduled hours.
A cultural crisis
Chronic underfunding and a lack of staff have also contributed to unsupportive working environments. Dr Sally Pezaro, a Nursing and Midwifery Council panellist, says limited opportunities for career progression and an adverse culture within the profession could be causing stress, and related absences.
The bottlenecking of top jobs, Pezaro explains, means those in them are anxious to keep them, contributing to “tall poppy syndrome” and a culture of competition. “If you want to grow, you'll be fighting against a load of other midwives to be in the top job,” she explains. “There’s a lack of opportunities for growth so if you do get a bit of progression you tend to hold on to it, and there might be a bit of squabbling to get there. Of those that do get the top jobs - tall poppies often get cut down, because they're seen as a threat.”
The damage that toxic working cultures can wreak upon patient safety was also noted in the Ockenden Review which lamented “widespread” bullying across the Shrewsbury and East Telford NHS Trust, with staff left crying in toilets as a result of behaviour ranging from deliberate undermining, to sarcasm, and belittling. Though Ockenden was confined in scope, earlier this year the Guardian revealed that many midwives who left the profession between 2018 and 2022 cited poor workplace culture as a motivating factor and in February an employment tribunal found in favour of Olukemi Akinmeji, a midwife who successfully sued one NHS trust for racist discrimination at the William Harvey Hospital in Kent. In its concluding remarks, the tribunal referred to a “toxic” environment, echoing the NMC’s Spotlight report which highlighted widespread discrimination and racism across the profession.
But, according to Pezaro, bullying is an issue that’s often tackled in a vacuum, if at all. “‘I don’t see enough people being reprimanded for bullying,” she says. “When people see it in front of their eyes, they just go ‘oh, that's just them,’ rather than addressing the problem or the wider system.” Though she sits on NMC panels, she explains that midwives who go through formal punishment processes for bullying are few and far between.
RCM officer Galvin is also cognisant of the problem. “We are very aware that there are cultural issues, and that does impact people’s health. If you don’t feel comfortable going to work and there isn’t support there either - that’s incredibly difficult.” Still, like Pezaro, she emphasises the importance of context. “It’s a vicious circle, because people are tired, people are burnt out, people are stressed, people aren't being supported and so people aren't being kind to each other, it all spirals.” This precarity also contributes to feelings of isolation, and the NMC Spotlight report found that ‘lack of support from colleagues’ is already causing midwives to leave the profession.
Though the NHS employs professional midwifery advocates (PMA)s who support, supervise and guide midwives, they are not bound to confidentiality, says Pezaro. “If you say to them, ‘I've made a big patient error’ or, ‘I'm drinking three bottles of wine a night to cope,’ then they have to report it to the NMC. So you can't really go to them and say what you really feel because you risk your reputation,” she explains.
While some midwives also have access to practitioner health programmes, most have to be referred by senior staff in order to access them. This, says Pezaro, is another erosion to confidentiality which does little to ameliorate the “stigma” of struggling with mental health.
The future: a dwindling profession
For new joiners, hostile working conditions can be particularly detrimental. The combination of adverse culture and staff shortages means that early career professionals and students “aren’t getting the support they need to develop their confidence,” says Galvin. Inconsistent support for new recruits was also stressed in the Spotlight report.
It found that many new entrants feel “shocked and overwhelmed” by the demands of practice in a way that extends beyond a novelty factor, and more along the lines of “inappropriate deployment”. Newly registered midwives also reported feeling “pressured to undertake tasks they felt they were either unprepared for or were inadequately supervised” as a direct result of staffing shortages.
“Even if midwives have time off, ‘they come back and realise it’s exactly the same’.”
Although there have been increases in the number of student midwives in recent years, the RCM says the positive impact of this has been undermined by the number of experienced midwives who are leaving the profession. It’s a phenomenon that Smith has seen first-hand. “We’ve got a real problem with recruitment and retention,” she explains. “We’ve got a huge amount of attrition with people finishing the course but not going into the job or newly qualified midwives leaving quite quickly as a result of not being able to manage the job or thinking – I don’t want to do this for 30 or 40 years.”
The issues can’t be much ameliorated by brief stints of sick leave or time off either, adds Galvin. Even if midwives have time off, “they come back and realise it’s exactly the same,” she says. “There’s still no staff, there's still no support, nobody's helping, and so they start to look for other employment and they're not just leaving the workplace, they're leaving the profession, because they feel so burnt out by it.”
The issue of low pay has only exacerbated stress levels and feelings of underappreciation. Last year the NHS Staff survey showed that just 21.7 % of midwives were satisfied with their pay, nearly a 10% drop from 2020. “I know a lot of midwives are really struggling financially, that often leads to them taking lots of bank shifts because they're trying to make up the money. Obviously that can lead to more problems, with burnout and sickness and stress,” explains Smith, who adds many midwives are disappointed with the pay deal negotiated by the RCM.
“It's such a stressful job; we're short staffed, and then we're not even being paid, sufficiently,” she explains. “The government is not on our side, and just takes us for granted, so there's a lot of really low morale because of that too.”
What needs to change
The consequences are multifaceted, and Smith specifically has coped by changing her working patterns. In 2018 she left hospital wards for a community team where she finds that shift patterns are more manageable. Still, there is no escape from chronic underfunding. “I've progressively cut down my hours,” she explains. “I'm now at work two days a week because I would find working full-time too stressful.”
Though the NHS workforce plan promises to invest in the retention and training of midwives, and in August NHS England announced additional funding for PMAs, some experts say the plans don’t go far enough. To ensure sufficient and systemic change, the RCM have called for [xx] with a view to making midwives feel more supported. “Retention is absolutely key,” says Galvin.
In addition to funding interventions, Galvin, Pezaro and Smith have also called for better enforcement actions against bullying behaviours, more accessible occupational health support, and flexible working. These are recommendations largely echoed by the RCM itself in its recent report on the workforce “crisis”.
More fundamentally, Pezaro says that “society as a whole doesn’t really value midwifery”, which for Laura stems from a patriarchal culture and disregard for ‘caring’ work generally. Tangible policy changes are essential, but a shift in how midwifery is perceived might be instrumental in securing them.
(*) Name changed to protect identity (requested).
Note: reference to NHS staff groups is drawn from terminology used in NHS sickness absence data; this also applies to the classification of clinical and non-clinical staff.