This is the second in a series of three articles exploring the staffing needs in the maternity services. Undertaking Birthrate Plus studies in hundreds of maternity units in the UK revealed a number of issues which affect any assessment of midwifery staffing needs in both hospital and community services. Using a simplistic approach of the annual births in a hospital as the sole basis for assessing staffing needs ignores the movement of women between different health trusts. Many hospitals provide care to women from outside their catchment area and this ‘cross border’ flow significantly affects the numbers of community midwives required. The patterns and policies of intrapartum care have a large impact upon hospital staffing needs, and these patterns vary across different services. Stand alone midwife-led units provide care for women in the community as well as for those who give birth within the unit. If required standards of midwifery care are to be maintained then more focused methods of calculating staffing needs must be used. This article will explore these issues and explain how ratios have been produced and which can be used to assess staffing needs based upon local information.
Since the start of 2001, 101 maternity units have entered the Birthrate Plus programme and of these 64 have completed their studies, with many more in progress. Although not designed or funded as a comparative study of midwifery workload and staffing needs, a coordinated analysis of the data gives a unique insight into demand for and patterns of midwifery care in England at the present time and has produced ratios of births:work-time-equivalent midwives which could form a basis for standards of care.
The workload in delivery suites can not easily be managed as women arrive in labour and give birth at any time in the day or night, and emergencies can arise at any time. Matching this dynamic work pattern with the necessary numbers and skills of midwives to meet agreed care standards is difficult. The Birthrate Plus Acuity tool has been designed to give midwives a prospective and predictive measure of client needs and the staff needed to meet those needs, and to assist the development of care policies in clinical governance. First developed with services in Wales, the Acuity system has now been used in a variety of maternity services. This is the third article in the series.
There was clear evidence that the ratio of hospital births:work-time-equivalent midwife is affected by the intrapartum case-mix related to clinical policies and uptake an epidural analgesia and by the volume of cross-border flow of clients between different units. Both of these factors were variable between different units. In many units the data showed that 40–50% of all cases had entirely normal labour and delivery while in others the figure was less than 25%. This raises issues about the potential for midwife-led care within main hospitals and the difficulty for midwifery managers in influencing clinical practice. Cross-border workload can be very high for some units and questions are raised about the costs of this ‘extra’ workload.
Birthrate Plus is a specifically midwifery-focused workforce planning methodology, which was designed to assess the numbers of midwives required to match the standard of providing all women with a minimum of one-to-one care from a midwife during labour. It uses a number of workforce planning strategies, such as a classification system for intrapartum care, recording of actual midwife hours required per category, further recording of all other maternal/midwife activity within hospital and community services, including home births, and uses a professional judgment and ‘expert group’ approach to assessing midwife hours per defined client need or activity. This article provides an outline of the theoretical framework and an overview of the results of Birthrate Plus studies within the NHS and beyond since 2001.
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