Nearly two decades ago, the role of the consultant midwife was recognised at national level across England, Scotland, Northern Ireland and more recently in Wales. In England, the role was introduced by the Department of Health and Social Care (DHSC) to encourage the development of clinical leadership, to retain expert clinical skills and to transform maternity services for the improvement of health outcomes for mothers and babies (DHSC, 1999). The report, Making a Difference, outlined the vision for the role to ensure that consultant midwives had the status and skills to directly influence service level changes to practice and systems and the care quality agenda. Comparing the progression of the role in midwifery, the focus was on strategic and professional leadership and similar visions were applied across all four countries in the UK (Department of Health Social Services and Public Safety, 2000; Scottish Executive Health Department (SEHD), 2001; National Leadership and Innovation Agency for Healthcare, 2010). Professional organisations such as the Royal College of Midwives (RCM) embraced consultant midwives as influential clinical experts with advanced midwifery practice (RCM, 2009), who work closely with obstetricians and departmental managers at all levels (Royal College of Anaethetists et al, 2007).
The functions of the consultant midwife are divided into four main areas: expert clinical practice, clinical and professional leadership, research and education, and practice and service development (DHSC, 1999; SEHD, 2001). Formal training and development for the role is inconsistent, however, with only one recognised programme being offered through the South Central Strategic Health Authority (RCM, 2013). In 2007, the publication Safer Childbirth featured consultant midwives as clinical leaders, with a recommendation of one whole time equivalent (WTE) consultant midwife for every midwife-led unit and 1 WTE for every for every 900 birthing women within a consultant-led unit, with the assumption that 60% of women would be classified as ‘low risk’ and will remain under midwifery care.
In Scotland, the introduction of the Keeping Childbirth Natural and Dynamic (KCND) programme documented the effect of consultant midwives in rolling out national programmes. Their task was to facilitate and negotiate change, act as role models for the clinical components and, in doing so, ‘prepare the ground for implementation’ (Cheyne et al, 2013: 115). The evaluation showed that consultant midwives were key to tailoring implementation and challenging practices in a multidisciplinary context. Given that Booth et al (2006) suggested that there were 27 consultant nurses and midwives in Scotland, with a further 6 posts approved, the addition of 14 consultant midwives through the national funding from the KCND programme contributed to a substantial growth at least for a 3-year period from 2007. Implementation is still emphasised at national level in Scotland as part of the education and careers framework (Scottish Government, 2010) and in support for advanced roles in non-medical professions (Workforce Planning and Development Unit, 2009).
It is clear that monitoring the growth of this role in midwifery is far from systematic, relying on occasional surveys and reports outside of government sources. A year after the recommendations from Making a Difference (DHSC, 1999) were published, there were ten consultant midwives in the UK (RCM, 2009). It was reported that the vast majority were specialising in normal birth, public health, and teenage pregnancy. This grew almost five fold in ten years to 48 consultant midwives, all of whom were working in England (Robinson, 2012). More recently, with the availability of workforce information by type of service in England, 77 ‘nurse consultants’ were reported as working in maternity as at September 2017 (NHS Digital, 2017). The category of nursing in this dataset is most likely to refer to midwives, and therefore this may provide another indication of continued growth of this role (Figure 1). However, equivalent, routinely collected data are not yet available for the other countries.
To support the role of consultant midwives in the UK, over the past 16 years the RCM has established an email- and meeting-based group, the ‘UK Consultant Midwives Network’ (RCM, 2017). This has maintained a community for consultant midwives to support each other and to engage with national agendas for midwifery and maternity services. Recognising the gap in the data required for workforce development and planning, the UK Consultant Midwives Network and the RCM worked together to carry out a comprehensive survey to determine the overall number of consultant midwives, their demographics and clinical specialities, and set up a process for mapping changes annually across the UK, the Channel Islands and the Isle of Man.
Methods
This study used survey methodology and an informal local intelligence gathering approach to estimate the number of consultant midwives and their role in maternity care in the UK, the Channel Islands and the Isle of Man.
Participation
The first phase of the study involved an open invitation to provide detailed information on consultant midwives in Trust/Health Boards in the UK, Channel Islands and Isle of Man, all of which are covered by the RCM. There are strong links for service development and delivery between the NHS equivalent organisations in the 6 countries, including training, therefore their inclusion was important for overall context.
The invitation to participate in the survey was disseminated using three main routes:
There were no restrictions placed on the role of the person completing the survey. Following the initial distribution of the survey link, a reminder was sent to the networks. This took place after 3 weeks of the first invitation and the survey was open for 8 weeks (November 2016–January 2017).
The second phase of local intelligence gathering was initiated in February 2017. Following the analysis of the data collected from Phase 1, areas of the UK, Channel Islands and Isle of Man that were not represented were contacted directly and information obtained about employment of consultant midwives. This also involved contacting RCM staff involved in professional engagement at national level in the Channel Islands and Isle of Man, Wales, Scotland and Northern Ireland, and at regional level in England. This was guided by the RCM structure for supporting professional engagement. There were no known consultant midwives working outside the NHS and the survey was not distributed to other organisations providing maternity care in the UK.
Data collection tool
The survey included both quantitative and open ended questions designed to capture information from organisations about:
The survey was designed to take less than 30 minutes to complete, either by a lead in the organisation or by the consultant midwives.
The survey was drafted by the project team and developed for online data collection using Survey Monkey. In order to test usability and time taken for completion, the survey was trialled by the study team and two consultant midwives. Following amendments, the final survey was released. As part of the local intelligence gathering, the survey link was made available to internal RCM staff involved in professional engagement in the six countries. The participants in this second phase of data collection were only able to report on the total number of consultant midwives in a given organisation and could not provide any further details.
Data analysis
As the data collection was online, it was available for use in spreadsheet format. The data was exported from Survey Monkey into Microsoft Excel, then reformatted for analysis. Due to the approach taken for data collection, there was the potential for duplication from the same organisation as individual midwives could complete the survey as well as a representative providing information for all the consultant midwives in the Trust or Health Board. Where two or more respondents had reported data for the same consultant midwife role, two researchers reviewed the data and merged the open-ended responses to form one response for the organisation. Where there were discrepancies in the quantitative information, the data was amended using the most reliable source (for example, age data provided by the consultant midwife would be accepted). Where there were disagreements between researchers on the merging of the data, the respondents were contacted and asked for clarification.
Two datasets were compiled for analysis with the first using the information collected at organisational level, and the second for the data on individual consultant midwives. The analysis was then carried out in Excel, mainly using pivot tables for the quantitative data. The responses to open-ended questions were manually analysed and summarised for main themes and insights.
Ethics and data governance
The survey collected information at Trust/Health Board level with no personal identifiers required. As the number of consultant midwives at an organisation level was expected to be in low, and demographic information could be traced back to a given individual, steps were taken to protect the datasheets. Access was provided only to the three researchers and analysis on sensitive information such as age, pay banding, and comments did not take place for areas with small numbers. Ethical approval was not required for this study as it was taking place through the Consultant Midwives Network and with the support of the RCM.
Results
Following Phase 1, there were 65 responses, with detailed information being provided for 72 midwives across 165 Trusts/Health Boards across the UK, Channel Islands, and Isle of Man. This represented a 100% response rate from the Trusts/Boards in all the countries with the exception of England. Phase 2, the local intelligence gathering, was therefore applied only to England.
A further 11 Trusts in England were identified as employing consultant midwives and 36 Trusts confirmed that they did not employ consultant midwives. After final analysis, responses were based on 68% (113/165) of the NHS Trusts and Boards with maternity services. Data completeness varied between 70–84% (depending on questions) for England and 100% for all the questions for the other 5 countries.
An overview of the status of consultant midwives
This study estimated that there were 84 consultant midwives working in the UK, Channel Islands, and Isle of Man, who were employed by 59 (36%) of Trusts/Health Boards. The vast majority were employed in English Trusts and there was no indication that consultant midwives were not directly employed by any of the organisations who responded to the survey. The survey identified 69 consultant midwives in England, with detailed information provided for 58 of them. This is an estimation of the total number available in the country given that 32% of the Trusts did not respond to the survey and it was not known whether they employed or engaged with consultant midwives (Table 1). The information for Scotland, Northern Ireland, Wales, and the Channel Islands and Isle of Man was expected to be representative of all the consultant midwives present in those countries. As Northern Ireland, the Channel Islands and the Isle of Man had fewer than 5 consultant midwives, a breakdown of demographic data at individual country level has not been presented.
| England | Channel Islands, Isle of Man | Northern Ireland | Scotland | Wales | Total | |
|---|---|---|---|---|---|---|
| Number of consultant midwives n (%) | ||||||
| Identified in the study | 69 | 1 | 2 | 6 | 6 | 84 |
| With responses in the survey | 58 | 1 | 1 | 6 | 6 | 72 |
| Trusts/Health Boards employing consultant midwives n (%) | ||||||
| Yes | 46 (34) | 1 (33) | 2 (40) | 6 (43) | 4 (57) | 58 (35) |
| No | 37 (27) | 2 (67) | 3 (60) | 8 (57) | 3 (43) | 54 (33) |
| Not known | 53 (39) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 53 (32) |
| Total | 136 (100) | 3 (100) | 5 (100) | 14 (100) | 7 (100) | 165 (100) |
Based on the data collected for the majority of the consultant midwives identified (87%), it was found that most were female (97%) and employed at Band 8 throughout the 6 countries (67%). They usually worked full-time (90%) and a large proportion (45%) had been employed for 5 years or more (Figure 2). For some countries, such as Northern Ireland and the Channel Islands, these were recent and first appointments into the role of consultant midwives, while in Scotland, the majority had 5–9 years of experience. The majority were aged 50 or more (64%) and in Scotland, all consultant midwives were in this age bracket (Table 2).
| Age (years) | England n(%) | Scotland n(%) | Wales n(%) | UK, Channel Islands, Isle of Man n(%) |
|---|---|---|---|---|
| Under 35 | 3 (6) | 0 (0) | 0 (0) | 3 (4) |
| 35-39 | 5 (10) | 0 (0) | 1 (16) | 6 (9) |
| 40-44 | 7 (13) | 0 (0) | 1 (16) | 9 (14) |
| 45-49 | 6 (12) | 0 (0) | 0 (0) | 6 (9) |
| 50-54 | 15 (29) | 3 (50) | 2 (33) | 21 (32) |
| 55-59 | 12 (23) | 2 (33) | 1 (16) | 15 (23) |
| Over 60 | 4 (8) | 1 (16) | 1 (16) | 6 (9) |
Reporting whether they had additional managerial responsibilities included in their roles, only consultant midwives working in England and Northern Ireland indicated that this was the case, with just over 1 in 10 (14%) stating that managerial responsibilities took up more than 20% of their time (Figure 3). Some consultant midwives (16%) reported having responsibilities outside of their primary role, such as responsibilities for Birth Centres or small teams of midwives:
‘I am responsible for 10 specialist midwives and they have other more junior midwives and support staff in their teams.’ (CM-ID-145)
‘I would call it more leadership of the 2 BCs [Birth Centres] as I have band 7 managers’ (CM-ID-97)
‘Responsibility for practice development team and birth reflections midwife.’ (CM-ID-109)
For those who reported that they had management responsibilities but could not allocate a proportion of their time, their responses were included under the category of ‘other’. These included responses about varied level of management responsibilities on a weekly basis, contribution to the out-of-hours on-call rota, or providing temporary cover to fill vacancies or for staff on leave.
A breakdown of the results shows that consultant midwives held roles that mainly focused on normality and public health (Figure 4). Intrapartum care was identified as the main area of speciality for four consultant midwives in England, which is likely to be focused in the acute care setting. The other areas highlighted were antenatal care, fetal medicine, maternal medicine, mental health, safeguarding, counselling, research, education, audit, and strategy. These speciality areas were limited to consultant midwives based in England. In addition to their key areas of focus, consultant midwives in England (n=5) also reported secondary specialist areas in mental health, safeguarding, counselling, research and audit.
For many of the Trusts and Health Boards, the consultant midwife role was only recently initiated and filled. In some cases, the creation of the role was attributed to structural changes in the organisation or ‘following CQC [Care Quality Commission] inspection’. Similar reasons were given for uncertainty in the near future for sustaining the roles:
‘Because of retirement and the post is unlikely … to be filled.’ (CM-ID-33)
‘Do not know [if role will change], but Trust in organisational change so anything is possible.’ (CM-ID-187)
‘Not sure, new HoM [Head of Midwifery] starting soon.’ (CM-ID-197)
‘Consultant midwife post created by previous HoM and (now) used for non-consultant midwifery roles. The role does not appear secure.’ (CM-ID-198)
The importance of support from senior management in initiating and maintaining roles was highlighted by respondents. Having strategic roles that fitted in with the wider remit for the maternity services, such as the meeting national targets or satisfying local commissioning needs were identified as beneficial:
‘Welsh target 45% of births supported to commence outside of an OU [obstetric unit] within 5 years.’ (TL-ID-20)
‘I also advise commissioners—maternity commissioning is now jointly performed by the local authority and CCG [clinical commissioning group].’ (CM-ID-19)
‘My role is very varied comprising all the elements of consultant midwife roles but does include a lot of strategic work as well as project work.’ (CM-ID-34)
Discussion
This is the first comprehensive intelligence gathering exercise for consultant midwives in the UK and the crown dependencies and one of the key findings was the variation in the distribution and roles of consultant midwives. Overall, growth was reported across all countries with the exception of Scotland, where the KCND programme resulted in a centrally funded 3-year growth that was not sustained. Although normality and public health were the most prominent areas of focus for consultant midwives, other specialties such as fetal medicine and maternal mental health were also highlighted in the responses.
The results revealed promising elements of consultant midwives' roles, such as strategic-level influences as well as clinical leadership for the care of women with complex needs. On the whole, these were in line with the core functions of the consultant midwife; namely those of expert clinical practice, clinical and professional leadership, research and education, and practice and service development (DHSC, 1999). In particular, supporting the implementation of strategic directions such as the Welsh Government's commitment to provide women with a range of services during labour and intrapartum care including at home and birth centres (Welsh Government, 2011). Many of these initiatives aligned with consultant midwives' specialties such as normality or public health (Royal College of Anaesthetists et al, 2007).
The study also highlighted areas of concern, including consultant midwives' additional managerial responsibilities and the sustainability of the role. Some 4 in 10 consultant midwives reported having managerial responsibilities, with the vast majority of these in England. These responsibilities could be argued to be detrimental to the clinical leadership function that is essential for consultant midwives to fulfil, as the leadership required to influence clinical practice as a consultant midwife requires a collegiate relationship with clinical colleagues, as opposed to a hierarchical relationship that forms the basis of managerial responsibilities (Edmondstone, 2009).
This study also highlighted the potential for instability in the consultant midwife role, despite the growth in most of the countries. Meeting women's needs in line with recommendations of one consultant midwife per midwifery unit, or one consultant midwife for every 900 women receiving maternity care, would require 500 more consultant midwives to be recruited. The open-ended comments also showed the potential for the lack of consultant midwives to increase, as job security was not guaranteed and succession planning was not in place. Given the positive impact that non-medical consultant roles have been shown to have (Guest et al, 2004), a reduction or stagnation of consultant midwife numbers is something that needs to be reviewed and counteracted with a clear strategy for growth.
‘Intrapartum care was identified as the main area of speciality for consultant midwives in England. The other areas highlighted were antenatal care, fetal medicine, maternal medicine, mental health, safeguarding, counselling, research, education, audit, and strategy’
Limitations of the study
There are two main limitations for this study. Firstly, in using a survey methodology to map the existing consultant midwives across the countries, it was difficult to ensure a full response rate, although the complimentary local intelligence used in this study provided reasonable assurance that most of most of consultant midwives had been counted. The continuous changes in the maternity service also meant that data were based on a point in time and changes need to be captured using routine data collections and annual surveys and counts. Secondly, the depth of questionnaire was limited in order to reduce the time taken by respondents to complete the survey. As a result, areas such as training undertaken, a detailed account of their role, and potential impact on the care provided for women and babies were not included as part of the survey. Given the need to grow consultant midwife roles substantially, further exploration is needed on the effect and benefits of this role on maternity care. There are frameworks and toolkits to build up this evidence-base, and this may in turn support the development of local level business cases for new recruitment or sustainability of these roles (Gerrish et al, 2011; Elliott et al, 2016).
Conclusion
This study provides an initial opportunity to understand the role and potential of consultant midwives based on policy and service drivers. Consultant midwives play a major role in maternity care, especially regarding normality and public health interventions, and have the clinical leadership and authority to implement key pathways and services. Given the clear message from this study that there are too few consultant midwives in the UK, Channel Islands and Isle of Man, with variation across geographical areas, there is a need to increase numbers over the next decade. The responsibility for measuring effect, monitoring growth and supporting sustainability sits at multiple levels including heads of midwifery services and the RCM; however, it is also imperative that maternity healthcare policy and education leads take an interest in reducing variation and supporting high quality maternity.