The Nottingham University Hospitals NHS Trust report has identified serious failings in care at one of England’s largest maternity services, with lessons for maternity units nationally. Among its findings was a repeated problem at the very start of labour: women and families struggled to access timely assessment and felt dismissed during telephone triage.
In several cases, women were discouraged from attending hospital when they believed labour had started, only to arrive later in established or advanced labour. In some cases, poor care during this period had serious consequences.
Across hospital-based maternity services, attention and resources tend to focus on women in more advanced labour, and those requiring induction of labour or caesarean section. This can mean services miss the chance to identify problems, offer reassurance and build trust at the very start of labour.
Listening to women and providing supportive care at the start of labour sets a woman up for a positive birth experience. Instead, research consistently shows that women report feeling unsupported and discouraged from coming to hospital in early labour.
Right at the start of labour, there is often a mismatch between the needs and expectations of women and the expectations and priorities of maternity services. Many women have long been told that hospital is the safest place to give birth. It is therefore unsurprising that they expect to be welcomed to the maternity unit where they are booked to give birth when labour starts.
The drivers of decision-making on the maternity services side are more complex. They include beliefs about early labour care, national guidance, unsuitable environments and workforce pressures.
Early labour
There is a widespread belief in many maternity systems that while women should give birth in hospital, they should not be admitted until they are in established labour.
This can result in midwives gatekeeping: discouraging or refusing admission in early labour. Women report receiving inconsistent advice, feeling unwelcome and dismissed and having to negotiate permission for admission.
This belief is influenced by international, national and local guidance. NICE guidance states that if a woman seeks advice or attends a midwifery-led unit or obstetric unit with painful contractions but is not in established labour, she should be encouraged “to remain at or return home”, unless doing so could mean she gives birth without a midwife present or becomes distressed.
The same guidance also says early labour assessment should include listening to the woman’s story, asking about her wishes, expectations and concerns, asking about the baby’s movements, offering support and agreeing a plan of care. The problem arises when “return home” becomes the default response, rather than the outcome of careful assessment and discussion.
A practical problem is that many maternity units are not designed or staffed to provide sustained early labour care. Historically, women in early labour were more likely to have access to antenatal ward beds or early labour areas, where they could receive midwifery support outside the labour ward.
As maternity care has shifted towards shorter stays, outpatient monitoring and day-case assessment, many services now have fewer options for supporting women before established labour.
The number of maternity beds in England fell by around 52% between 1987-88 and 2019-20, mainly because women spend less time in hospital before and after birth. Antenatal beds were removed or repurposed to streamline maternity processes, but this also reduced care options.
The result is that many maternity units now lack a suitable environment to care for women in early labour. When there is nowhere appropriate for women to be supported, they are more likely to be encouraged to go home.
Workforce pressures
At the same time, workload and the complexity of women’s care needs have increased. There has been a rise in caesarean birth rates in England, with NHS maternity statistics showing that 45% of deliveries in NHS hospitals in England in 2024-25 were by caesarean section.
Induction of labour has also become more common. These changes increase care requirements for women and babies, particularly on labour wards. Staffing models have often struggled to keep pace with workload and the need for safe, personalised care.
Organisational demands exert significant pressure on midwives to keep women out of hospital and to make decisions based on bed availability and staffing rather than on the care needs of mother and baby.
Midwives have described not admitting women in early labour because of staff and bed shortages. Some have even described hiding women on labour wards because they knew they needed care, while trying to avoid disapproval from senior staff.
The result is a service that can fail to support women at a time when they and their birth partners feel most vulnerable. It is time for a rethink.
Early labour care must be organised around women’s needs and safety, rather than institutional pressures alone. That means properly staffed assessment, clear return plans, dedicated early labour spaces where possible, and workforce models that include time for assessment, reassurance and support.
Research from Denmark, Sweden and Switzerland suggests that early labour care works best when it is accessible, individualised and organised around women’s needs rather than simply her stage of labour. In the Danish study, women had access to a dedicated early labour unit and staff received training to emphasise the importance of early labour care. The wider findings highlighted the value of clear plans, emotional support, continuity and flexible care. This change was brought about in one of Denmark’s busiest units (6,500 births), and is a lesson on how UK maternity units could work with women to improve care.
The Nottingham report shows what can happen when women’s concerns are minimised at the very start of labour. Getting that first contact right will not solve every problem in maternity care, but it is a practical place to begin.
Women need to know that if they call because they are worried, in pain or unsure, someone will listen properly. Early labour may be the beginning of birth, but it should never be the point at which care is weakest.
