The Big Question: Why is there a crisis in maternity care, and should parents be worried?

What is the problem?

The Royal College of Midwives says the shortage of staff and facilities on labour wards has reached "crisis" point. The Royal College of Obstetricians has warned of a lack of skilled obstetricians and a looming recruitment crisis as the number of UK medical graduates choosing obstetrics has halved in a decade. On Wednesday, MPs demanded urgent action to address the problem in a Commons debate. A BBC Panorama programme broadcast this week, filmed undercover in two hospitals in north London and Manchester, claimed wards were buckling under the midwife shortage.

Is Britain a safe place to have a baby?

Yes, according to the Government. The UK remains one of the safest countries in the world to have a baby, the Department of Health said. Increased investment will see the number of midwives rise, it added.

Critics say there are worrying indicators. A shortage of skilled obstetricians on the wards has led to a rise in emergency Caesareans, performed because of a failure to progress in labour, which now account for more than a third of all Caesareans. (The rest are planned.) The RCOG says many emergency Caesareans could be avoided if more consultants skilled in managing difficult labours were available.

Although neo-natal deaths (in the first four weeks) and infant mortality (deaths in the first year) have improved in the past decade, the stillbirth rate has remained unchanged since 1990 and is likely to rise as mothers delay childbearing and obesity continues to rise.

Britain's maternal death rate at 7.31 per 100,000 births in 2000-04 is above the EU average at 6.84, according to the World Health Organisation. Specialists fear that the disaster at Northwick Park hospital, where 10 mothers died in childbirth in five years, well above the national average, could be repeated elsewhere. The Healthcare Commission, the government inspectorate, ordered special measures to set the Northwick Park maternity unit back on track which were lifted last year.

Why is there a shortage of midwives?

The Department of Health says that there are 2,084 more midwives working in the NHS since 1997 (to 2006) and there has been a 44 per cent increase in students training to be midwives. The Royal College of Midwives says that though numbers rose in the earlier part of this period, they fell by 375 between 2004 and 2006. A poll of 102 out of 216 department heads found that two-thirds said their units were understaffed and one in five said they had lost staff in the past year.

The college complains that while other parts of the NHS have seen huge increases in staff and resources over the past decade, midwifery has not benefited to the same extent. The proportion of the NHS workforce represented by midwives dropped from 2.1 per cent in 1997 to 1.7 per cent inn 2005.

Doctors claim that only one midwife in three is working at any time, as more choose to work part-time for agencies, which supply staff to the NHS to cover holidays, sickness and unsocial hours. A midwife working long hours could potentially earn up to £80,000 a year at agency rates compared with £24,000 to £26,000 for the NHS.

As hospital trusts have run into financial difficulties over the past two years, they have cut back on agency staff leaving their own staff to cover. Agency midwives have chosen not to go back to working for NHS rates.

Don't falling birth rates ease pressure on the system?

The birth rate is going up. There were almost 50,000 extra births in England in 2005 compared with 2001, a 9 per cent increase in five years from 564,871 to 614,237.

In London the increase has been fuelled by immigration, chiefly from the new member states of the EU. According to Philip Steer, editor of the British Journal of Obstetrics and Gynaecology and senior consultant at Chelsea and Westminster Hospital, one in three births in London is now to a parent not born in the UK. The influx of young people has been good for the economy but birth rates have risen 20 per cent in some parts of the capital in the past two or three years, and there has been no proportionate increase in maternity provision.

Are all hospitals equally safe?

No. Obstetrics is a high-risk specialty and there is always a fear that babies will be born brain damaged if things go wrong. Obstetrics accounts for the highest proportion of clinical negligence claims against the NHS with pay outs running into millions of pounds.

The NHS Litigation Authority, which handles negligence claims against NHS trusts, ranks trusts according to their estimated level of risk, based on a detailed assessment, published on their website. Of 160 hospitals and community units providing labour wards, just 13 have the top ranking (level three) denoting lowest risk and two have the bottom ranking (level zero) denoting high risk.

Can women trust their obstetricians?

It depends. As in all walks of life, some doctors are better than others - but the profession is still doing too little to identify the poor performers. A pilot study at Liverpool Women's Hospital, the largest maternity unit in Europe with 8,000 deliveries a year and one of the safest in Britain (ranked level three by the NHS Litigation Authority) found one in eight registrar obstetricians was performing below par.

The study was based on two measures - failed attempts at ventouse delivery (using the suction cap) and failed attempts at amniocentesis - which were used as an indication of the doctors' all-round skill. The researchers led by Andrew Weeks, who published their findings in the May issue of the British Journal of Obstetrics, say it was easy to identify the doctors whose performance was "below acceptable success rates" and provide extra training and supervision to bring them up to scratch.

But they admit that most units don't know what their failure rate is and don't try to identify the poor performers because of fears that they will become victims of a witch-hunt. Over the three years from 2003-4 to 2005-6, the Liverpool Women's Hospital ventouse failure rate fell from 19 per cent to 12 per cent, in part due to the monitoring of obstetricians' performance.

What does the future hold?

In Maternity Matters, published last month, Patricia Hewitt, the Secretary of State for Health, set out the Government's vision of a woman-focused maternity service, with more choice and more emphasis on home births by 2009.

The Royal College of Midwives says an extra 3,000 midwives will be required. The Royal College of Obstetricians says there are concerns about the safety of home births. Mothers say it is the well-being of their babies that counts and nothing else matters.

Are staff shortages putting pregnancies at risk?

Yes...

* The number of midwives has fallen in the last two years, and two thirds of units say they are understaffed

* Birth rates are rising, and in some areas such as London the increase is as a result of immigration

* The number of medical graduates choosing obstetrics has halved in a decade

No...

* There are over 2,000 more midwives working in the NHS today than in 1997

* Infant death rates are lower and childbirth is safer than it has ever been

* The practice of ranking hospitals according to their risk and monitoring staff performance improves safety

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