Members of the union representing midwives in Scotland have rejected the latest NHS pay offer.
The Royal College of Midwives (RCM) said 65% of members voted against it. The union will now consider next steps including possible industrial action.
The NHS offered an average pay increase of 7.5%. It was accepted by Unison and Unite members but rejected by the GMB.
The Scottish government has said the proposal was unprecedented at a time of "extraordinary financial challenges".
The Royal College of Nursing has also rejected the pay offer and said it would soon announce dates for strikes.
Jaki Lambert, RCM director for Scotland, said: "Our members have spoken loud and clear – the latest pay offer by the Scottish government is simply not good enough. It goes nowhere near addressing the rising cost of living and would see many midwives actually worse off in real terms.
"Our members have been consistent throughout this process – they want a decent deal, and they are prepared to take industrial action to get one.
"No midwife wants to do this and it is for the Scottish government to make sure that they do not feel that they are left with no other option.
"While we acknowledge that the Scottish government has listened to some of the concerns regarding career opportunities and development, it has failed to meet our members' needs on pay."
Last month, Holyrood ministers tabled an improved pay offer averaging 7.5% to health workers threatening industrial action.
Annual salary rises under the proposal would range from a flat rate payment of £2,205 for staff in Bands 1 to 4 and up to £2,660 for staff in Bands 5 to 7, backdated to April.
This represents an increase of 11.3% for the lowest paid workers and delivers an average uplift of 7.5%.
Unite and Unison chose to accept the deal, however, the GMB union became the first to reject it last week.
The Scottish government said previously that the pay offer was unprecedented for front-line employees and would ensure NHS workers in Scotland remain the best paid in the UK.
The RCM is part of the Scottish Terms and Conditions Committee (STAC), which negotiates pay deals with the Scottish government. STAC staff will meet with ministers on Thursday to share the outcomes of their respective consultations, the RCM said.
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