The King's Fund calls for new approach to staffing in maternity units

Using midwives and other maternity staff more effectively is the key to improving maternity care in hospitals, according to a new report, Staffing in maternity units: getting the right people in the right place at the right time, from The King's Fund. Despite the fierce debate over midwife numbers, increasing staffing levels will not be easy in the current financial climate. Evidence shows that the maternity workforce could be utilised more effectively to improve outcomes for mothers and babies.

The report recommends deploying midwife-led care much more widely for women at a low and medium risk of problems, with the potential to improve outcomes for women and babies and to save costs to the NHS. In 2009/10, only 10 per cent of hospital births in England took place in midwife-led wards.

The report identifies other ways in which care could be organised more effectively within maternity teams. Shifting tasks from doctors and midwives to nurses and support workers where appropriate could free up the time of midwives to provide one to one care for women and doctors to focus on supporting women at higher risk of problems and would help to ensure that there is adequate consultant cover available 24 hours a day.

The report also calls for further development of the Birthrate Plus tool, which has been used for a number of years to plan midwifery requirements and to determine midwife-to-woman ratios. Although the tool is popular and is widely used, it does not take into account the contribution that other staff can make.

Anna Dixon, Director of Policy at The King's Fund said:

'Midwife-led care should be the norm rather than the exception. Midwives' time must be used more effectively with an increased use of maternity support workers, doulas providing lay support and specialist nurses. This would free up doctors to spend more time caring for higher-risk women. Having sufficient staffing levels is important, but there is a need to rethink how staff are deployed. I hope this report will facilitate a wider debate about maternity care that recognises the need to organise the workforce more effectively.'

In common with the rest of the NHS, maternity services face significant challenges over the next few years. Demographic changes mean that a rising birth rate coupled with the increasing complexity of many births has increased the pressure on services. With the NHS needing to find up to £20 billion in efficiency savings by 2014/15, the report argues that improving productivity through better deployment of the maternity workforce may be a more realistic goal than significantly increasing staffing levels.

Read the report: Staffing in maternity units: getting the right people to the right place at the right time

Notes to editors: 

For further information, or to request an interview, please contact the press and public affairs office at The King's Fund on 020 7307 2585 (if you are calling out of hours, please ring 07584 146035).

The report, Staffing in maternity units: getting the right people in the right place at the right time, was informed by work commissioned by The King's Fund from academics in England, Australia and Canada led by Professor Jane Sandall at King's College London. It considered safety in labour and birth for women and babies via a literature review and interviews with key UK stakeholders about the improvement of practice through workforce changes. To read the report, please visit The King's Fund website.

Most women and babies do better under midwife-led care around labour and birth when compared with doctor-led care or models where different professionals share responsibility for their care. In 2009-10, 10.1% of hospital births in England took place in midwife-led settings, with the remainder of births in doctor-led care or shared care units, according to NHS Maternity Statistics, 2009-10. (see Table 1: Place of delivery, 1989-90 to 2009-10)

Midwife-led care is associated with several significant benefits for mothers and babies, and not with adverse effects. Women receiving midwife-led care in hospital are less likely to be hospitalised after the birth, and are less likely to have episiotomy and an instrumentalised birth. Among the benefits of midwife-led care, they are also more likely to have a spontaneous vaginal birth, to feel in control during  the birth and to initiate breastfeeding.

Writing in The Sun newspaper in January 2010, David Cameron said midwives were 'stretched to breaking point', 'overworked and demoralised', and pledged that he would 'increase the number of midwives by 3000'. RCM is campaigning on the fulfilment of this pledge and have spoken of the need for '4,700 more midwives in England to provide a safe and high quality service for women'.

The report found that ensuring quality and safety in wards is not solely dependent on the absolute numbers of staff, but is also associated with the skill mix and the deployment of staff. The same, or better, outcomes for women were linked to an extended midwife role. The potential benefits of the appropriate use of maternity support workers and neonatal nurses in freeing up midwives' time were also highlighted in the findings.

While the overwhelming majority of births in England have been shown to be safe, evidence shows that a systematic approach to ensuring safety across maternity services is lacking, which can create unnecessary risks. From September 2009, the Safer Births service improvement programme run by The King's Fund with national and local partners has worked to improve the safety of maternity services by supporting frontline professionals and sharing good practice.

The King's Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.