Caesarean Surge Puts 20 England Maternity Units at Risk

Up to 20 of England’s 155 consultant-led maternity units may have to close or change role, an NHS managers’ group has warned. Matthew Hopkins, acute-care director at the NHS Alliance, said smaller wards that deliver 1,500 to 2,000 babies a year cannot keep a safe 24-hour service.

The pressure is not only missing doctors. Caesarean births have reached 45% of deliveries in English NHS hospitals, and that surgical load is what small rural and coastal units can no longer staff.

Up to 20 Consultant-Led Units Face Closure or a Changed Role

Hopkins, who has run four hospital trusts, told interviewers on 19 October that centralising childbirth into fewer hospitals was “inevitable” and “the right thing”. He said ministers must back changes that will send some women further to give birth, or watch small units fail in a rush.

The NHS Alliance speaks for health managers. It says units at the 1,500 to 2,000-birth mark, often in rural or coastal areas, cannot hold a full obstetric, anaesthetic and neonatal rota while so many births now need an operating theatre. Hopkins put the number of places where that squeeze may force a shutdown or a change of role at 20. He said the current layout of maternity care is “not fit for purpose”.

THE SCALE OF THE WARNING

• Consultant-led units: England has 155 NHS maternity services led by consultant obstetricians.
• At risk: Hopkins said as many as 20 may need to shut or change their role.
• Small-unit threshold: Wards delivering 1,500 to 2,000 babies a year are the ones he called increasingly hard to keep safe.
• Cover required: Those sites still need round-the-clock obstetric, anaesthetic and neonatal staffing as surgery replaces unassisted birth.

He said the recent shutdown in north Devon “was not a one-off” and that decaying buildings, too few theatres and too few beds add to the risk. Hospital bosses, he added, fear the government’s maternity taskforce will skip those “strategic” questions if it will not say how the NHS should absorb the caesarean rise.

Difficult decisions lie ahead, consolidating maternity services to support safer, more sustainable care. If politicians are keen to see safe maternity services in their area, it is going to need courage to grasp the nettle.

Matthew Hopkins, Director for Acute Care, NHS Alliance

He also said that if the caesarean share moved to 55% or 65%, trusts would be forced into reactive closures. His case is that the NHS should move first, while it can still plan.

England Now Does More Caesareans Than Unassisted Births

NHS England’s maternity statistics for 2024-25, covering April 2024 to March 2025, show that 45% of hospital deliveries were caesareans. That share overtook unassisted vaginal births for the first time in the published series. The same release recorded 542,235 deliveries, 0.5% fewer than in 2023-24.

A decade earlier, in 2014-15, NHS hospitals in England recorded 636,643 deliveries and a caesarean share of 26.5%. The operation rate has climbed 18.5 points while the number of births has fallen. Hopkins and Marian Knight, professor of maternal and child population health at the University of Oxford, have used a shorter arc: 33% in 2020 to 45% in 2024-25, a 12-point jump.

ENGLAND NHS BIRTHS AND CAESAREAN SHARE

Each caesarean needs a surgeon, an anaesthetist, a theatre and a longer stay. NHS Digital’s 2024-25 delivery tables show 75% of women with a spontaneous birth went home the same day or the next day, against 45% after a caesarean. A small unit built around mostly vaginal births is being asked to run like a surgical hospital without the staff or the rooms.

Births Fell While Surgical Work Rose

Falling deliveries do not ease that load. Fewer babies still mean more operations when nearly half of births are surgical. Knight has argued that the NHS should consider consolidating into fewer, bigger maternity units so teams can handle the caesarean surge. Hopkins said he shares that view.

NHS England has linked the rise to more women choosing a planned operation and to more diabetes and obesity in pregnancy. Dr Alison Wright, president of the Royal College of Obstetricians and Gynaecologists, has also pointed to better detection of a baby in trouble during labour. The college’s own audit work still reaches the same operational point: units have to be staffed and equipped for the births they now do, not the births they did ten years ago.

Women Over 40 Now Face a 59% Caesarean Rate

The surgical share rises with age. For women under 30, unassisted vaginal birth is still the most common method. From 30 upwards, caesarean is the most common. For women aged 40 and over, 59% of deliveries are caesareans, according to the same NHS Digital tables.

That age pattern lands hardest on smaller hospitals. They already struggle to recruit consultants. They now also need extra theatre lists for older, more complex pregnancies. Hopkins’s warning is that a ward of 1,500 to 2,000 births cannot keep that list safe at night.

North Devon Has Already Sent 197 Births to Exeter

The live test is North Devon District Hospital in Barnstaple. Birthing services there have been suspended since 11 August because the Royal Devon University Healthcare NHS Foundation Trust could not guarantee senior medical cover. A planned 29 September reopening was pulled after a staffing check failed.

In a 14 October update the trust said a readiness assessment on 12 October had still not cleared a restart. It said 197 women from northern Devon had given birth at the Royal Devon and Exeter Hospital since the pause, with no confirmed safety incidents tied to the suspension. The next assessment is on Monday 26 October. Reopening, if it comes, would follow two weeks later.

Prime Minister Andy Burnham, answering questions on 2 September, said it was “not acceptable” for expectant mothers from north Devon to give birth in Exeter, a 70-minute car journey from Barnstaple. Jess Bailey, chair of Devon County Council’s health scrutiny committee, said she was “appalled” that closing smaller units including Barnstaple was now on a national agenda, and called on Health Secretary Yvette Cooper to reopen the ward and keep it staffed.

THE BARNSTAPLE SHUTDOWN

1. 11 August 2026: Birthing services at North Devon District Hospital are suspended after the trust says locum cover and mutual aid cannot keep the rota safe.
2. 29 September 2026: A provisional reopening date is missed. Chief medical officer Dr Vanessa Purday says the date was always conditional on staffing and that this is not a decision to close the service for good.
3. 12 October 2026: A further readiness assessment finds the agreed safety criteria still unmet. Consultant vacancies remain, and an international recruitment campaign is launched.
4. 14 October 2026: The trust reports 197 births moved to Exeter and no confirmed safety incidents linked to the suspension.
5. 26 October 2026: The next readiness assessment is due, with any restart still two weeks after the criteria are met.

Hopkins used that case as proof the map is already moving. The same pattern has shown up elsewhere, including outside England, wherever a small obstetric rota has to cover a surgical birth rate.

WARDS ALREADY FORCED TO STOP OR MOVE BIRTHS

• Barnstaple, north Devon: Consultant-led births have been paused since 11 August, with 197 women sent to Exeter and the next safety check set for 26 October.
• Yeovil, Somerset: The maternity unit reopened in 2026 after being shut for almost 12 months because it had too few staff.
• Daisy Hill, Newry: Southern Health and Social Care Trust chief executive Steve Spoerry said the trust is planning to move inpatient births to Craigavon Area Hospital from 23 November if it cannot fill consultant posts. The unit needs eight consultants for a safe rota.

A distant theatre can look safer on a spreadsheet than it feels in labour. Some second labours do not wait for a 70-minute drive. Size is not a safety certificate either. Several of England’s worst maternity investigations involved large units, not cottage hospitals. The open question is whether merging small wards adds theatre capacity, or simply moves the shortage down the road.

Doctors and Midwives Say Do Not Close Local Wards

The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists both rejected closure as the first answer. Hannah Leonard, chief policy officer at the midwives’ college, said women and families rely on local units “to be there when they need them” and that high-quality care must stay close to home.

Wright said other answers to the workforce gap are “far safer than closing maternity units” and should be tried first. In a BBC interview she said the government should expand the maternity workforce, invest in training and retention, and recognise the distinct needs of smaller rural and coastal units.

We urgently need services to be supported to adapt to changing patterns in childbirth, with appropriate staffing, training, facilities, and sustained investment.

Dr Alison Wright, President, Royal College of Obstetricians and Gynaecologists

That line, from the college’s response to a Great Britain birth-trends audit, is the colleges’ core offer: adapt to changing patterns in childbirth by staffing and building, not by deleting the local ward. Helen Morgan, the Liberal Democrat health spokesperson, put the travel risk in harder words, saying that forcing women in labour to travel an hour or more is “unsafe, unacceptable, and leaves local communities abandoned”.

The objection that keeps returning is simple. Closing a 1,500-birth unit does not create a consultant. It lengthens the journey for the woman who still needs one. If the 45% caesarean rate is treated as fixed, Hopkins’s math looks grim. If part of that rate is a staffing and culture problem, as some midwives argue, then shutting the small ward locks the surgical model in place.

Delayed Caesareans in the Latest Death Review

The strongest evidence for Hopkins is not a managers’ briefing. It is the latest MBRRACE-UK confidential enquiry into maternal deaths. In 2022-24, 252 women in the UK died during pregnancy or within six weeks, a rate of 12.80 per 100,000 maternities. That rate is 20% higher than in 2009-11, when a previous government set a target to halve maternal deaths in England by 2025.

Thrombosis and blood clots were the leading cause (42 women), then heart disease (39) and mental health conditions (35). Black women died at 32 per 100,000, against 12 per 100,000 for White women, a 2.7-fold gap. Women in the most deprived areas died at twice the rate of those in the least deprived (18 per 100,000 against 9).

Assessors also followed women whose planned caesareans were delayed. In one case a scheduled operation was postponed twice, by eight days in total, because of theatre availability and workload. Assessors wrote that capacity for caesarean sections is becoming a patient safety issue. The report’s first national recommendation is that health departments review theatre and workforce capacity against changing maternal characteristics and caesarean rates.

WHAT THE 2026 MBRRACE ENQUIRY PUT ON THE RECORD

• Deaths: 252 women died in 2022-24 during pregnancy or within six weeks, at 12.80 per 100,000 maternities.
• Trend: The rate is 20% higher than in 2009-11, and direct maternal deaths rose faster than the overall figure over that span.
• Inequality: Black women faced a 2.7-fold higher death rate than White women, and the most deprived areas twice the rate of the least deprived.
• Theatres: Planned caesareans were postponed for lack of theatre time, and assessors called caesarean capacity a patient safety issue.

That finding cuts both ways. It supports Hopkins when he says a unit without enough surgeons and theatres cannot run a 45% caesarean service. It also supports Wright when she says the fix is more staff and more theatres, including in the places that still have a labour ward. A closure that lengthens the road to the only remaining theatre can recreate the delay the enquiry just recorded.

The December Plan Has Not Named a Single Ward

Baroness Amos’s independent National Maternity and Neonatal Investigation, published on 30 June, concluded that the system is no longer fit to give consistently safe, compassionate care. Her team heard from more than 450 families, received more than 10,500 responses to a call for evidence, and visited 12 NHS trusts. She set out eight recommendations, including a statutory maternity and neonatal commissioner.

Senior figures had already told her that poor buildings and “too little (political) backing for difficult reconfiguration decisions” sat among the barriers to better care. Hopkins is now asking Cooper’s taskforce to supply that backing. The Department of Health and Social Care did not comment directly on possible closures. A spokesperson said every woman deserves safe maternity care, that the secretary of state has made the issue a personal priority, and that the taskforce she chairs will deliver reforms.

On 30 June the government said a national action plan due in December would overhaul services. It announced a further £41 million for maternity and neonatal facilities on top of £145 million committed since April 2025, plus 1,000 temporary posts to help newly qualified midwives join the NHS, backed by more than £10 million. It also extended Martha’s Rule to maternity and neonatal wards, so a parent can demand a rapid second look if a mother or baby is getting worse.

None of that names a ward. None of it adds a consultant to Barnstaple’s night rota this month. Another national document that restates safety without theatres, obstetricians and a decision on small units will leave the 45% caesarean rate to keep redrawing the map by default.

WHAT WE KNOW

• The warning: Hopkins says up to 20 of 155 consultant-led units may need to close or change role because of obstetrician shortages and a 45% caesarean rate.
• The live closure: Barnstaple has not taken births since 11 August, 197 women have delivered in Exeter, and the next readiness check is 26 October.
• The death data: MBRRACE-UK recorded 252 maternal deaths in 2022-24 at 12.80 per 100,000, and called caesarean theatre capacity a safety issue.
• The timetable: Cooper’s taskforce is due to publish a national action plan in December.

WHAT IS UNCONFIRMED

• Which 20: No official list of units has been published, and ministers have not endorsed Hopkins’s figure.
• Barnstaple’s restart: The trust has set no reopening date and still has consultant vacancies.
• Daisy Hill: The Southern Trust has not taken a final decision, though it is planning for 23 November.
• The December plan: It is not yet known whether the action plan will back consolidation, fund small-unit rotas, or leave local fights to each trust.

The next readiness check at Barnstaple is on Monday 26 October. The national action plan is due in December. Neither has named which labour wards will still take births.

Disclaimer: This article is news reporting on NHS maternity services, official statistics and published safety reviews. It is for information only and is not medical advice, and it does not tell any reader how to plan a birth, whether to have a caesarean, or where to seek care. Anyone who is pregnant, planning a pregnancy, or worried about symptoms should speak to a midwife, GP or obstetrician and follow the advice of the team providing their care. Figures, unit statuses and political timetables are those given by the NHS bodies, trusts and official reports cited here, and they can change as staffing checks and the December action plan move on.