The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).
This page summarises the report's findings on the reconfiguration of maternity services.
Proposals reviewed by NCAT
- Concentrating consultant-led obstetrics services onto fewer hospital sites
- Creating, maintaining or closing stand-alone midwife-led birthing units
Key drivers of maternity service reconfiguration
Workforce, dependency on paediatrics, cost and safety were the primary drivers of this type of reconfiguration.
Context and relevant policy
- NHS England commissioning guidance encourages:
- compliance with NICE guidance (see below)
- adequate staffing and a skill-mix and deployment which ensures that midwives are able to deliver continuity of antenatal and postnatal care
- achievement of 1:1 care in labour measured either through patient reported outcome measures (PROMS) or using agreed tools such as the National Patient Safety Agency (NPSA) scorecard
- evidence of access to all types of intrapartum care: home birth, midwife-led environments (freestanding or alongside units), and obstetric-led environments.
- Most births (87 per cent in 2012) take place in obstetric units, with 11 per cent in midwife-led units and 2.4 per cent at home (National Audit Office 2013).
- The number of obstetric units in England has fallen slightly from 180 in 2007 to 177 in 2010. In 2010, all acute trusts had a maternity service, 97 per cent had an obstetric unit, 35 per cent had an alongside midwife-led unit and 24 per cent had a midwife-led birthing unit.
- In 2007, the annual number of deliveries in a midwife-led birthing unit ranged from 8 to 548; for an alongside midwifery-led unit, it ranged from 93 to 2,860; and for deliveries in obstetric units, it ranged from 914 to 6,781.
- Birth rates fluctuate. After a period of decline, they rose for most of the past decade, but fell by 0.6 percentage points in 2013 (Office for National Statistics 2014).
- The mean age of mothers at childbirth is rising, with the numbers of women giving birth over the age of 35 rising steeply. Adverse pregnancy outcomes rise with age and women over 40 have a higher risk of complications, so the complexity of births that obstetric services must manage has been increasing.
The current evidence base
To minimise the risk of complications and poor outcomes for high-risk women, senior obstetricians should ideally be present on the labour wards 24/7. But there is no evidence on the minimum number of doctors required to achieve this. Current Royal College of Obstetricians and Gynaecologists (RCOG) job planning guidance limits obstetric ward-based commitments, magnifying the number of doctors needed to deliver 24/7 cover. Obstetric units need dedicated anaesthetic support, with the capacity to transfer women to critical care if necessary. Specialist mental health services should be available.
There is no clear relationship between outcomes and the size of obstetric units. There is a need to balance the benefits of centralisation with the risks from the loss of local access. Stand-alone midwife-led birthing units are a safe option for low-risk mothers, and home birth is a safe option for low-risk mothers who have already had children. There are questions about the financial sustainability and the capacity to staff stand-alone midwife-led birthing units. It may be possible to sustain obstetric units with lower levels of consultant cover if they focus on low-risk births and have robust transfer arrangements. Midwifery staffing levels need to support 1:1 care during labour irrespective of the setting.
Relevant college and other guidance
The Safer childbirth guidelines recommend 60-hour consultant presence for units of 2,500–4,000 births per year, 98 hours for 4,000–5,000 births per year, and 168 hours for more than 5,000 births per year.
RCOG has argued that centralising obstetric services so that units have at least 6,000 births per year would enable the current workforce to support 24/7 consultant presence in all units. But it does not recommend centralisation in all cases.
The Royal College of Midwives (RCM) and others recommend the Birthrate Plus® (BR+) workforce planning tool to plan staffing levels that take account of differing local needs, case-mix and midwifery skill-mix in order to meet the requirement for one-to-one care.
24-hour availability (within 30 minutes) of consultants and 24-hour resident cover by a ST1/2 or an advanced neonatal nurse practitioner (ANNP), who is trained and assessed as competent in neonatal life support and whose only responsibility is to the neonatal and maternity services (RCOG et al 2007).
Stand-alone midwife-led birthing units
RCOG and RCM have supported the provision of intrapartum care in stand-alone midwife-led birthing units, but RCOG suggests that this only applies for multiparous, low-risk women. The RCM emphasises the reduced interventions and other benefits of stand-alone units and regards them as valuable choices available to women in a maternity service portfolio.
Draft NICE guidance recommends that commissioners and providers should ensure that all women can choose their from four different birth settings: obstetric unit, stand-alone midwife-led birthing unit, alongside midwife-led birthing unit and home birth.
NICE further recommends that ‘low-risk’ multiparous women should be advised to give birth in a midwife-led unit (stand-alone or alongside) or at home because the rate of intervention is lower and the outcome for the baby is no different compared with an obstetric unit. NICE also recommends that ‘low-risk’ nulliparous women should be advised to give birth in a midwife-led unit. However, as there is an increased risk for first-time births planned at home, they recommend that first-time mothers are advised of this risk.