Maternity wards need the right people in the right place at the right time

Barely a month goes by without an article in the press on the shortage of midwives and hard-pressed maternity departments struggling with their workload. But is it just about the numbers of staff, or could the situation be improved if maternity services changed the way they use their current workforce?

Absolute numbers of staff are, of course, important, and services are coming under more pressure thanks to a rising birth rate, a growing number of older mothers with pre-existing long-term conditions, and many midwives approaching retirement. However, a significant increase in the number of midwives is looking more and more unlikely as NHS budgets are squeezed and commissioners look for savings across the board. The pledge made by David Cameron last year to provide an additional 3,000 midwives looks set to remain unfulfilled.

So, what can be done? The King's Fund's inquiry into the safety of maternity services concluded that the key to improvement is effective deployment: the right staff doing the right thing at the right time in the right place. Unless effective deployment and the right skill mix are achieved, simply increasing staff numbers will have limited impact. We have explored this further with our report, Staffing in maternity units: Getting the right people in the right place at the right time, looking at evidence from around the world of different models investigating ways in which maternity units can better use the staff they do have without compromising safety during labour and birth.

For me, the most striking finding is the potential for task-shifting. Highly qualified medical staff – who should be focused on the highest risk women – currently perform tasks that midwives could do just as effectively, while midwives perform duties that could be undertaken by nurses, and nurses, doctors and midwives undertake clerical work that should be done by administrative staff. This has serious implications for the safety and cost-effectiveness of services.

Continuous lay support during labour has also been associated with positive birth experiences, and some NHS units are now using doulas, who stay with the mothers during labour. Of course they do not replace midwives but, in providing continuous support to women throughout labour, they allow midwives to focus on delivering the care they have been trained to provide. This is a relatively recent phenomenon in NHS maternity services, but it holds the potential to deliver better care for women and their families. More maternity support workers are also being employed, and they appear to play a valuable role by freeing up midwife time. However, there are currently no standards in place for their training and clarity is needed about the scope of their role.

Further use of midwife-led services also appears to hold potential for improving standards. The UK already has a relatively high use of midwives when compared to other European nations – Germany and Spain, for example – which have obstetrician-led approaches, but there is still further potential to extend midwife-led care to low- and medium-risk women. So far, evidence shows that midwife-led care not only offers a range of better outcomes but also has the potential to deliver cost savings by freeing up the obstetric workforce to focus on the most complex cases.

This report should make positive reading for maternity services – although it doesn't claim to solve all the problems, it does highlight some ways to deliver greater productivity without compromising on safety.

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Comments

#366 rebecca

The ethos of midwifery is 'to be with woman' regardless of if she is high risk or low risk or in the middle. Who draws the line to decide which women 'deserve' midwifery care? surely it is the 'right' of every woman? If you remove the 'tasks' out of midwifery care you remove the opportunity for relationship building, woman will often tell you their 'worst fears' or 'lowest moment' when you are taking a blood pressure or emptying a bed pan. Continuity of care is the key. Serving women is a privilege which does not need compartmentalising, deconstructing and destroying. We need more midwives to undertake the holistic care package. One to one midwifery care saves lives, improves outcomes and womens experiences it is not an optional extra. We should be working towards saving midwifery not destroying it.

#367 Robert

Wouldn't one-to-one care be great for everyone? This report does not suggest 'destroying' midwifery but rather it it puts the onus on midwives to 'step up to the plate' and demonstrate the delivery of the ethos suggested by rebecca. This ethos must be delivered by the maternity team and not by midwives in isolation from doctors and maternity support workers - it is about getting thye right skill-mix for the maternity care pathway.

#368 rebecca

More midwives would be the answer then-like the government promised!

Midwives 'step up to the plate' every shift, there are simply not enough midwives for the amount of plates!

The multidisciplinary team is alive, kicking and working effectively I am not suggesting that it should change, however I am suggesting that instead of deconstructing the Midwives role, and passing it's content out to others, we allow midwives to do the job that they are trained for and passionate about.

If you would like to see effective one to one midwifery care that changes lives-employ and train more midwives

#369 Denise
Midwife

Not this old chestnut again!! I am a passionate proactive midwife who after 24yrs service often struggles to remember the reason for my passion - The WOMEN and babies we have the privilage to provide care for!! Midwifery is an art providing woman centred holistic care and not a task orientated profession!! Our profession has been decimated by midwives giving up parts of their role to other maternity assistants while loosing clinical time by taking on expanded roles in place of medical staff such as examination of the newborn. Please lets get back to the basics where midwives are where we belong - WITH WOMAN!!!!

#371 Maureen Treadwell
Birth Trauma Association

There are many positive elements in this report and it asks important questions about how maternity staffing can be better used. There do, however, seem to be a few omissions particularly a) the failure to take into account the vital issue of what women actually want b) little analysis of opportunities to redirect resources into staffing which is currently wasted on litigation.

Repeated surveys - the Tina Lavendar study for RCOG, studies such as Investigating Women's preferences for Intrapartum Care by Longworth, Vanora Hundley’s work on Assessing Women’s Preferences not to mention the huge Mumsnet outcry over the denial of epidurals last week - all serve to emphasise that the general public have reservations about midwifery led care. Many women want to be looked after by midwives but not in the absence of doctors, anaesthetists and the trappings of 21st century medicine. There is a lot of literature on this which seems to have been missed. There is a clear and passionate divide between those who favour midwifery ethos based on promoting physiological birth and those who would argue that the concept of ‘naturalness’ is alien in a world where there is hardly anything in modern life is natural. The fact that women who choose midwifery led care appear happy with their choice does NOT mean that satisfaction overall would be improved by more midwifery care. This is a complete fallacy. Conjoint analysis as carried out by Longworth shows that they are an entirely different group of women to those who want CLU care. The latter group would be vociferously opposed to being forced to give birth in low risk settings. These are cultural not clinical issues – there is as much division amongst clinicians as among the public. The NHS therefore needs to be inclusive in its provision of services and not make provision for one group at the expense of the other.

The Rachel Joyce study showing that consultants make a substantial difference to perinatal mortality should not have been so lightly dismissed in the current report. We clearly need more midwives but also more anaesthetists, more obstetricians and further development of neonatal services. More research is needed in this area to analyse the impact of different grades of staff and staffing levels on outcomes and litigation. There may well be the resources to pay for this if litigation is reduced.

Above all, there needs to be a single cohesive service – one service that brings together midwifery, obstetrics, obstetric anaesthesia and neonatology as well as GP and Health Visitor services. Less ‘midwife led’ or ‘consultant led’ and more maternity team leadership. There is no such thing as a ‘low risk’ woman or a ‘high risk’ woman – risk can ebb and flow by the second and there needs to be a seemless flow and good communication and shared values between the maternity professions if services are to be delivered safely. The Kings Fund ‘Safe Births’ Enquiry is perhaps one of the most enlightened assessments of maternity care that has been written in recent years and so further development of its excellent recommendations particularly on communication and interprofessional team working are needed.

Could the Kings Fund include representatives from the Royal Colleges (BAPM for neonatology, RCOG, RCM and Obstetric Anaesthetists) as well as GPs and a range of user groups as pre publication reviewers in some of the work arising from future reports arising from the Safe Births Initiative? This could significantly strengthen future reports. If a key message of the Safe Births enquiry is that the professions must work together better, then that needs to start from ‘think tank’ level right down to the front line troops!

#373 W. Beaufort
Doctor

"The King’s Fund’s inquiry into the safety of maternity services concluded that the key to improvement is effective deployment: the right staff doing the right thing at the right time in the right place".

Gosh. And that inquiry cost how much, precisely?

#377 Marco Cornejo
Public Health MSc
U. de Chile

Interesting article, I suggest studying about Chile's experience. A country with good indicators of maternal and child health health and health care.
Prenatal care comissioned to midwives nurses, has expanded the coverage of prenatal care, the institutionalized parrt and more efficiently than in other environments where the task is in charge of human profesional resources in lower cost and more effectiveness.

#1044 ulani

if the doulas are the continuous support during labour - what exactly does that free up the midwives to do? oh yes - paperwork. midwives should be with the women - if that's what women want of course. and the doulas should be looking after the women's household in other ways - siblings, food, comfortable environment etc - attuned to what makes the woman feel good in the perinatal period - in partnership with mws not in lieu of them.

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