Midwifery Leadership in a Changing World - Why Is This So Challenging. A Narrative Review

Background Midwifery leadership is recognised as essential to delivering safe, high-quality, and person-centred maternity care. Despite extensive investment in leadership development and governance frameworks, numerous national reviews in the United Kingdom continue to highlight leadership as a persistent weakness in maternity services. Understanding the factors that constrain effective leadership is critical to achieving sustainable improvement. Aim This paper explores why midwifery leadership in the UK remains so challenging. It reflects on national evidence, leadership theory, and the author’s professional experience to consider the cultural, structural, and personal dimensions of leadership in maternity services. Methods A reflective approach is adopted, drawing on over 30 years of professional practice across clinical, academic, and national improvement roles. The discussion integrates findings from national inquiries, academic research, and international comparisons, with leadership theories including compassionate, courageous, and adaptive leadership. Findings Midwifery leadership is shaped by complex and competing pressures, including rising clinical complexity, workforce shortages, cultural tensions between midwifery- and medically-led models of care, and punitive governance systems that foster fear. These conditions undermine psychological safety, contribute to attrition, and limit opportunities for succession planning. Evidence suggests that effective leadership behaviours—compassion, courage, adaptability, and systems thinking—can strengthen team resilience and improve outcomes. International models demonstrate how supportive policy environments and greater autonomy enable midwifery leadership to flourish. Conclusion Effective midwifery leadership is both an individual and a structural endeavour. Leaders must demonstrate relational, values-driven behaviours, while systems must dismantle punitive cultures, invest in leadership development, and embed frameworks such as Safety-II. Without cultural and organisational reform, even skilled leaders will struggle to thrive, jeopardising progress towards the ambitions of the NHS Long Term Plan.