6th October 2026
Scotland has a population problem.
The number of births is falling, the population is ageing and in many parts of the country deaths now substantially outnumber births.
Yet at the same time, Scotland is having a very different conversation about maternity services.
Today, the Scottish Government announced another independent review of maternity services across Scotland. It will examine the future organisation of maternity care and will pay particular attention to rural and island communities, including Caithness and Elgin.
The review will take nine months, with recommendations expected in 2027.
And that raises an uncomfortable question.
Could some of Scotland's approach to maternity services actually be working against its desire to maintain the population of rural Scotland?
Scotland really does have a population problem
The latest figures from National Records of Scotland are stark.
There were just 45,067 births in Scotland in 2025, the lowest annual total since records began in 1855.
The total fertility rate fell to 1.23 children per woman, also the lowest figure in the NRS published series.
For a population to replace itself without migration, the fertility rate would need to be around 2.1.
Scotland has not reached that level since 1973.
There were also 61,726 deaths in 2025.
That means Scotland had almost 17,000 more deaths than births.
The population nevertheless increased slightly because migration more than offset the natural decline.
But that creates another question.
Can a country deal with long-term population decline simply by importing population through migration?
Migration will inevitably be part of Scotland's demographic future. But if the Government wants young Scots and young families to remain in Scotland, particularly in rural areas, then the conditions in which they live matter.
Having a baby is not simply about having a baby
For a young couple considering where to live, work and raise children, housing and employment are obviously important.
So are schools.
Childcare matters.
Transport matters.
And maternity services matter.
Nobody should have to choose a home simply because of the location of the maternity unit.
But equally, nobody can blame an expectant mother for wanting to know where she will give birth and how far she may have to travel if something goes wrong.
That becomes particularly important in rural Scotland.
Caithness provides an uncomfortable example
Caithness has already experienced the consequences of maternity centralisation.
Following the downgrading of consultant-led maternity services at Caithness General Hospital in 2016, women have faced journeys of around 100 miles to Raigmore Hospital in Inverness to give birth.
The issue has been repeatedly raised in the Scottish Parliament.
For someone living in Wick, that is not simply a slightly longer journey to hospital.
It is a journey down the A9 to Inverness.
For a woman in labour, or for a partner trying to accompany her, distance becomes much more than a number on a map.
And this is not about criticising the medical staff.
The Scottish Government itself acknowledges that maternity services in areas with relatively small numbers of births create difficult questions about how safe and sustainable services can be organised.
That is a genuine problem.
But so is the effect on the community.
What message does this send to young families?
Imagine being a young couple living in Caithness.
You are considering buying a house.
Perhaps you have employment.
Perhaps you like the community.
You might even want to have children and bring them up locally.
Then you start looking at the practicalities.
Where will the children go to school?
What childcare is available?
How far is the nearest hospital?
Where will my partner give birth?
What happens if there is an emergency?
How long will we have to travel?
These questions do not necessarily determine whether somebody has a child.
But they are part of the wider question of whether somewhere feels like a good place to build a family.
Should women make fertility a weapon?
This is where the argument can easily go down the wrong road.
Women should not be told to have children for the sake of Scotland's population statistics.
Nor should women be encouraged to stop having children as a form of protest.
Having a child is an intensely personal decision involving health, relationships, finances, housing, employment and countless other considerations.
But there is another way of looking at it.
Women do not need to make fertility a weapon.
They simply need to have confidence that if they decide to have a child, the society in which they live will provide reasonable support.
That includes safe and accessible maternity care.
And if confidence in those services is reduced, government should at least consider whether that could have wider consequences for decisions about where young families choose to live.
The contradiction in rural Scotland
This is where Scotland's population strategy becomes particularly interesting.
The Scottish Government is concerned about population decline in parts of Scotland.
National Records of Scotland says that deaths outnumbered births in 20 of Scotland's 32 council areas in the year to mid-2025.
Some rural and island communities face especially difficult demographic pressures.
Yet some of the services that help make those communities attractive places to raise families are being centralised because of staffing, safety and sustainability pressures.
That creates a difficult circle.
Fewer births can make a local service harder to sustain.
A reduced local service can make an area less attractive to families.
Fewer families can then mean fewer births.
And the demographic problem becomes even harder to reverse.
That is not necessarily what is happening in every community, and it would be wrong to claim that maternity services are responsible for Scotland's falling fertility rate.
There are much wider forces at work, including housing costs, the cost of raising children, changing attitudes towards family size, delayed parenthood and economic uncertainty.
But maternity services are one piece of the puzzle.
And now Elgin has another delay
The timing of today's announcement is particularly interesting because Moray is also dealing with continuing uncertainty.
Maternity services at Dr Gray's Hospital in Elgin were downgraded in 2018.
The intention had been to restore full consultant-led maternity services by the end of 2026.
That has now been delayed until next year.
So women in two areas specifically named in today's national review — Caithness and Elgin — are once again being asked to wait for answers about the future of their maternity services.
For Caithness, the issue has been running for a decade.
For Moray, the original downgrade dates back eight years.
And now there is another review.
Reviews are useful — but families need certainty
The Scottish Government is right that maternity services need to be safe.
There is no sensible argument for retaining a service that cannot provide safe care simply because a community wants it.
The new review is also genuinely independent and is intended to examine the future needs of the population, including rural and island communities.
But there is a difference between reviewing a service and delivering a solution.
Caithness has already experienced years of reviews, discussions and uncertainty.
Elgin has experienced years of delay.
The danger is that another review simply produces another period of waiting.
If Scotland is serious about population decline, perhaps maternity services need to be viewed as part of the population strategy rather than simply as an NHS management problem.
What would make young people stay?
Perhaps the question should be turned around.
Instead of asking:
"Why aren't young people having more children?"
perhaps government should ask:
"What would make young people confident enough to build their lives and families here?"
The answers are unlikely to be found in one policy.
They involve decent jobs, affordable housing, childcare, schools, transport, healthcare and communities where people believe their children will have opportunities.
Maternity services are one visible part of that wider package.
And in rural Scotland, where the nearest alternative may be many miles away, they can be particularly important.
Scotland cannot simply import its way out of population decline
Migration has become the main reason Scotland's population continues to increase.
That is not necessarily a bad thing. New residents contribute skills, work, taxes, businesses and community life.
But migration cannot by itself solve the underlying demographic imbalance.
If deaths continue to exceed births by large margins and rural communities continue to lose younger people, Scotland will remain dependent on attracting people from elsewhere simply to maintain its population.
Perhaps that is acceptable.
Perhaps it is not.
But it should at least be an explicit choice rather than an accidental consequence of decisions made separately by health, housing, education, transport and economic policy.
Population policy needs to connect the dots
Scotland has a population policy.
It has a maternity policy.
It has a rural policy.
It has a housing policy.
It has an economic strategy.
And it has policies aimed at encouraging families to stay and prosper.
The problem is that these policies do not always appear to be talking to one another.
A maternity service can be perfectly rational from the perspective of NHS workforce planning.
A population strategy can simultaneously say that Scotland needs more young families.
Both statements can be true.
But if they produce a situation in which young families become less confident about living in remote Scotland, then somebody needs to join the dots.
Perhaps Scotland's population problem is not simply about how many babies women have.
Perhaps it is also about whether young people believe Scotland is a place where they can safely build a future for their families.
Women do not need to make fertility a weapon.
But governments should understand that confidence is part of fertility policy too.
If Scotland wants more children, it needs to think seriously about what kind of Scotland those children will grow up in.