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.
This blog also featured on the Guardian Healthcare Network website.