(copyright Birthrate Plus(R); May 2009)
Introduction and overview
In recent years there has been increasing need to produce some basis for recommending ratios of births per w.t.e. midwife to enable large-scale workforce planning based upon projected annual hospital and home births. 

Birthrate Plus® has made a number of contribution to large scale planning by drawing on it's data gathered from detailed workforce planning studies in maternity services across the United Kingdom. (DOH 2003, Ball et al 2003, Ball 2004, 2005)

in 2007 we first offered differentiated ratios linked to different levels of service; details of which follow,  and we can provide different options for workforce planning using these ratios together with local information..........please see separate section on different options for workforce assessment. The data for studies undertaken in 2008 has now been added to the database and the ratios have been reviewed, and apart from the ratio for community care, remain the same.

The remainder of this report provides details of the ratios and the issues which underly their use.

The ratios provided in the reports cited above was focussed on national planning and quoted a figure of;
28 births per w.t.e. midwife for hospital births (including all aspects of midwifery care in hospital and community ) and
 35 births per w.t.e. midwife for home births.
This could then be used to assess staffing needs based upon projected annual births of for example; 600,000  hospital and 50,000 home births. 

However when planning is based at Strategic Health Authority, PCT or service level, planning needs to take account of local factors and service level issues and more clearly focussed ratios need to be applied.

BIRTHRATE Plus® Database; 2006 –2008
The results of Birthrate Plus® (BR+) studies which cover the detailed analysis of hospital and home births and related staffing needs. Since 2006 the detailed results from 120 studies in England have been compiled on a database. The results are based on a total (over four years) of 385,490 hospital and 8500 home births.

Analysing these data has made it possible to identify a number of factors which impact significantly upon staffing needs at SHA and PCT level.

Identifying these factors and their effect upon staffing defined ratios will be crucial as Maternity Matters( DOH 2007) highlights the need for all commissioners to review their midwifery staffing needs.

This paper will explore these changes and indicate appropriate ratios of births/cases per w.t.e. midwife for National, SHA and  PCT level
 

Those familiar with the Birthrate Plus Midwifery Workforce Planning system will know that it is based upon the principle of providing one to one care during labour and delivery to all women with additional midwife hours for women in the higher clinical need categories (Ball and Washbrook 1996).

A BR+ study assesses the midwifery workforce of a service based upon the needs of women and records data for a minimum period of 4 months on intrapartum care, hospital activity, and all other aspects of care provided by midwives from pregnancy till the mother and baby are discharged from postnatal care.

Note; more information about the parameters used to assess staffing needs and information about the BR® intrapartum scores and needs categories can be found in the appendices.

RATIO FOR NATIONAL PLANNING
The ratio for national planning cited in the reports noted above is usually quoted as 28 births per w.t.e. midwife for hospital births and all related community care. The data showed that the mean ratio was in fact 27.68 with a range of 24.8 to 30.4 which illustrates how local variations can affect staffing needs. The ratio for home births is 35 births per w.t.e. midwife.

Changes in workload
In 2006 and 2008 the NICE guidelines for antenatal care led to a change in midwifery workload and this has now been reflected in the staffing profiles for BR+.
At the same time a clear reduction in the length of postnatal stay for some women in the higher category groups was noted and this created changes in the distribution of workload between hospital and community midwifery services. As a result the national ratio of 28 births per w.t.e. midwife needed to be reviewed 

The calculation of workforce needs and subsequent ratios quoted in this review  take these changes into account and are based upon data from England from 2006 onwards.

(note: recent data has been compiled from some maternity services in Wales and Northern Ireland is not yet analysed; Scotland is currently undertaking a nationwide study via Birthrate Plus®)

The national ratio based upon data from 2006,2007 showed a mean ratio of 28births per w.t.e. midwife. The data for 2008 indicates a slight increase but it is not suggested that the well established national ratio of 28 births should yet be changed.

The ratio of 35 births per w.t.e midwife for home births remains the same.

MOVING ON WITH CALCULATING STAFFING  NEEDS BY DIFFERENTIATED RATIOS
In the paragraphs that follow; a number of factors, which have a marked impact upon calculation of staffing needs and ratios, will be explored and a method of making allowances for overcoming their effect explained

Issues to take into account;
1). Level of service provided by different hospitals
Hospital services providing tertiary level care will by definition have a larger proportion of women needing higher levels of antenatal and intrapartum care and this affects the staffing needs.
Please also note later comment in 2.2b below.

2). Cross border flow between different PCT's and Hospital services.
These ‘flows’ have three main effects upon staffing demands and service costs.

2.1 Women flowing out of the PCT; Many women who are resident in one PCT area give birth in another, and therefore are not recorded among the local births, meaning that their community based care has not been included in the staffing parameters.

2.2 Women flowing into hospitals within a PCT:
Most hospital services provide care to women who are non–resident within the PCT in which the hospital is situated. This has two effects;
a) the local hospital births; w.t.e. midwife ratio is artificially increased as it does not provide the community based care received by all women.

b) if workforce planning is based upon local population births only, then the hospital care provided for women who are non–resident in the PCT will not be included. 

Although some of this flow between services may be due to clinical needs much more often it is due to social and geographical reasons.
There is no relationship between the size of type of hospital service and the volume of cross border activity.

3. Stand alone Midwife led units/ Birth Centres and some smaller maternity hospitals provide a range of care to women not all of whom will give birth within the unit. Some will be booked with the service, but during pregnancy or labour will need to be referred to consultant care and their births recorded in the hospital to which they are referred.

Other work undertaken by MLU's include providing ante and postnatal care to local women booked for consultant care, some units "host" consultant led
clinics, and many also provide community based care.

Therefore  assessing their performance or staffing needs on a ratio based solely on the births taking place within the unit will be inaccurate.

PROVIDING AN ANSWER:  RATIOS FOR USE BY SHA'S AND PCT'S

Birthrate Plus® analyses of the 2006/2008 data has been undertaken in order to:
1. Verify the context for assessing ratios in the NHS

2.  In relation to DGH's  and Tertiary Services indicate local factors, which impact upon staffing ratios.

3. Overcome the problems of wide variation in cross border activity in different situations.

4. Produce and test a simpler and more locally relevant format for calculating staffing needs by breaking down ratios into hospital only and community only segments of workforce needs in order to enable closer correlation with types of hospital and patterns of care

5. Discuss special needs of stand alone Midwife led units and units caring for less than 2000 births per annum and suggest ways in which units may more accurately predict staffing requirements and indicate further research to be done.

Results of analysis of data showed that;
1. When hospital and community services are assessed jointly i.e. with one ratio to cover all midwifery workforce, then the volume of cross border activity, which varies considerably across services, obscures the clinical factors that affect workload/workforce issues.

2. When hospital care is assessed separately a clear correlation can be seen between the intrapartum care outcomes measured by Birthrate Plus® case-mix. This has advantages for clinical governance as staffing needs especially in intrapartum care can be more readily monitored.
Details of the casemix categories used by BR+ can be found in the appendix.

3. When community care is dealt with separately, it is much easier to assess staffing needs based on local population.

As a result we now recommend that workload and workforce assessments are based upon;
Hospital services based on recorded births and differentiated by service level
Community care based upon the number of women booked for care each year.

Details of the ratios follow.

See later comments re Stand alone midwifery units/BirthCentres

Differentiated Ratios For Workforce Planning

1. Hospital births: w.t.e. midwife ratios;
Based upon the recorded  live and still births p.a. in per hospital but defined by their casemix and level of neonatal care; as follows;

a. Tertiary level services    38 births per w.t.e. midwife

b. DGH's with a casemix showing that more than 50% of birth outcomes fall in the higher need BR+ categories of IV and V; 42 births per w.t.e. midwife

c.  DGH's with a casemix showing that less than 50% of birth outcomes fall in the higher need BR+ categories of IV and V.  45 births per w.t.e midwife

(Note: any of the Tertiary/DGH's listed above may also have an integrated midwife led units/ section; this does not affect ratios as all births are recorded as a total for the hospital)

   2. Community cases: w.t.e. midwife ratios
  a) Community care for women who give birth in hospital;   98 cases per w.t.e. midwife  (see note below)

  Community midwifery workload ratios should be based on the number of
  women  booked for  ante and postnatal care irrespective of where the
   birth takes place. In this way all local women resident within a PCT will have their care allowed for and cross border activity is no longer an issue.

Note; The previous ratio for community care was 100 cases per w.t.e. midwife. Analysis of latest service data recorded in 2009 shows that the ratio has reduced to 98 cases per w.t.e. midwife. This is because of the increase in time for antenatal care as a result of impementing the latest NICE guidelines on early assessment of need.  

  b) Home births: w.t.e. midwife ratio  Assessment is based on the number of expected or targeted home births per annum and added to the community care workforce   Home births 35 births per w.t.e. midwife

Using ratios for workforce planning
More information and advice on using these differentiated ratios and other information (see below) is available from Birthrate Plus® to assist local commissioners and service planners to produce a staffing profile based on their local situation.

Further advice & support are available from Marie Washbrook e-mail: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it .

Other concerns for maternity care planners

1.Stand Alone Midwife Led Units
These vary widely in their patterns of work but data available indicates that;
it is not correct to measure workload simply by the number of births taking place within the unit.

Nor can a single ratio be produced on the number of births or cases booked. Although more data is needed, at present our data show the following
patterns of work from which it would be possible to produce a staffing profile;

· Number of women booked all receive ante and postnatal care even if they eventually give birth elsewhere
· Births in the unit can use the same ratio as home births
· There is a good deal of work arising from peri-intrapartum care; categories X, A1, and transfers either in labour or  post-delivery and it may be possible to  add the w.t.e. for this work as a percentage of that needed for births
· Some units also provide in patient postnatal care for women who give birth in the hospital, and may be their own cases returning or can be women who have earlier discharge from hospital and receive the remainder in the MLU
· Some units also host Consultant led "outpost" clinics and other antenatal services

Guidance can be offered on how to assess stand alone MLU/ Birth Centres based upon local patterns of activity.

Deployment of midwives/skill mix issues
The BR+ ratios will enable services at SHA and PCT level to accurately calculate its staffing needs for hospital and home births, and community care based upon local information.

Deployment of those midwives and decisions about their deployment is a matter for local management. However, advice can be offered based on experience in working with numerous maternity services.

Caseload based care; Midwives for Caseload based model of midwifery care, which spans both hospital, and community are already included in the overall staffing calculation.

Specialist midwives, managers, etc; these specialist and management midwives are very much a local decisions, however the BR+ data records the numbers of these other midwives in relation to size and type of unit and could offer advice if needed

Maternity Care Assistants: Distinguishing between hospital and community services will more easily enable midwifery managers to determine the use of maternity care assistants.

Finally; the  Birthrate Plus®  Consultancy Team have been priviledged to work with so many Maternity Services and wish to acknowledge all the work undertaken by local midwives in compiling the robust and detailed data upon which these ratios are based.

The following appendices provide further information on the parameters of care and allowances included in the staffing ratios, and the classification system for  intrapartum care upon which the case-mix, and mean hours of midwife care per category are based

Appendix 1.  Parameters Of Care And Staffing Allowances included in the ratios

For all calculations of w.t.e. midwives;
21% Hols/Sick And Study Leave (can be changed if local allowances differ)
1% for Supervision of Midwifery

Community based staff; Home, Caseload and Community care for hospital births
17.5%  Travel Time Allowance (can be changed where local patterns apply)

Community care for hospital births
12 –15 hours for all antenatal and postnatal care including parentcraft depending upon the birth outcome and neonatal needs.

Home Births;   All antenatal and postnatal care as above, plus an allowance of 17 hours for intrapartum care including second midwife present for the birth, and first follow up visit.

Hospital Ratios include the following;
· Measured workload for antenatal outpatient activity including clinics and day units,
· All antenatal impatient activity, plus ward attenders
· recorded details of intrapartum case-mix and mean midwife  hours required per category, plus workload for other peri-intrapartum care (Cats X, A1 ,A2, re-admissions, transfers, and inductions)
· postnatal care in hospital
· neonatal examination of the newborn

Appendix 2;

Method For Classifying Birthrate Plus® Categories By Scoring Clinical
Factors In The Process And Outcome Of Labour And Delivery

The Score Sheet is completed at the time that the woman leaves the delivery suite.

All women in labour require careful monitoring of their physical condition, the process of their labour, accurate assessment of the condition of the fetus and sensitive emotional support.  Such aspects of care are regarded as basic for all women.  The scoring system is designed to identify and weight these fundamental requirements together with other key indicators of increased needs.

There are five [5] categories for mothers who have given birth during their time in the delivery suite [Categories I – V)

CATEGORY I   Score  = 6
This is the most normal and healthy outcome possible.  A woman is defined as Category I [lowest level of dependency] if:

The woman’s pregnancy is of 37 weeks gestation or more, she is in labour for 8 hours or less; she achieves a normal delivery with an intact perineum; her baby has an apgar score of 8+; and weighs more than 2.5kg; and she does not require or receive any further treatment and/or monitoring

CATEGORY II Score = 7 – 9

This is also a normal outcome, very similar to Category I, but usually with the perineal tear [score 2], or a length of labour of more than 8 hours [score 2]. IV Infusion [score 2] may also fall into this category if no other intervention.

However, if more than one of these events happens, then the mother and baby outcome would be in Category III.

CATEGORY III Score = 10 – 13

Moderate risk/need such as Induction of Labour with syntocinon, instrumental deliveries will fall into this category, as may continuous fetal monitoring.

CATEGORY IV Score = 14 –18

More complicated cases affecting mother and/or baby will be in this category, such as elective caesarean section; pre-term births; low apgar and birthweight.  Women having epidural for pain relief and a normal delivery will also be Category IV.

CATEGORY V  Score = 19 or more

This score is reached when the mother and/or baby require a very high degree of support or intervention, such as, emergency section, associated medical problem such as diabetes, stillbirth or multiple pregnancy, as well as unexpected intensive care needs post delivery.

Note; Other workload in the delivery suite is also recorded i.e. women who require care but do not give birth during that visit to delivery suite.

References
Department of Health 2003  Report to the Department of Health Children's Taskforce from the Maternal and Neonatal Workforce Group- Jan 03 

Ball J A, Bennett B, Washbrook M, Webster F.
Birthrate Plus Programme: a basis for staffing standards?
  British Journal of Midwifery :Vol11, no. 5 pp 264-266 May 2003

Ball J A, Bennett B, Washbrook M, Webster F.
Birthrate Plus Programme: Factors affecting staffing ratios
British Journal of Midwifery :Vol11, no. 6 pp 357-361 June 2003

Ball J A, Bennett B, Washbrook M, Webster F.
Birthrate Plus Programme: Further issues in deciding staffing needs
British Journal of Midwifery :Vol11, no. 7 pp 416-419 July 2003

Report To NHS Workforce Planning Review Team;  May 2004

Information From Birthrate Plus Database As  A Contribution To The DOH Recruitment And Retention Of Midwives Debate Working Group                                   May 2005

Department of Health 2007 Maternity Matters.; Choice, access and continuity of care in a safe service.