All the materials used within a Birthrate Plus(R) Workforce Planning study are included in;

On this page we have tried to answer some of the basic questions about Birthrate Plus, but readers are also urged to refer to other pages in this website, especially; 

More information........outlines what is and is not included in a Birthrate Plus study

Feedback from Midwifery Managers

Tips from Project Midwives  

Use and Validation of BR+

1. HOW DOES BIRTHRATE PLUS WORK? 

What are the basic principles of Birthrate Plus?

Any workforce planning system needs:

• a method for assessing the workload generated by the number of clients and their different levels of care
• the standard of care to be met
• a means of recording staff hours required to meet those needs standards
• and a formula to convert the data into staffing requirements.

Birthrate Plus is based upon the standard on one to one care from a midwife for a woman during labour and delivery, together with the care of the newborn infant(s)

A classification system was developed which uses clinical indicators to place mother and baby in one of five outcome categories.

Full details can be found in the manual (Birthrate Plus; Ball and Washbrook 1996) and other pages on this website. The score system was designed to be easy to complete and has been applied to hundreds of thousands of mothers and babies in UK and abroad. It has remained the same since publication.

A further classification is used for women who receive care in the delivery suite, but who do not give birth during that visit, and this has recently been put onto a separate score sheet in response to changes in practice.

How does the score system work?

The score system is a retrospective score and is completed when the mother and baby are ready to leave the delivery suite. It is based upon clinical indicators of the process and outcome of labour for mother and infant, and others which demonstrate increased need or any emergency intervention.  

Each of these indicators is weighted to reflect the degree of need, and the resulting total score classifies mother and infant into one of five outcome categories (I - V). We use roman numerals for the categories so as not to confuse them with data during analysis etc.

Categories I and II reflect normal labour and outcome and are predominantly midwife led care. Categories III - V reflect increasing levels of need. Category III are women who may have had an induction of labour, continuous fetal monitoring for known or suspected rick and instrumental delivery. Category IV might be  a woman who has had a well managed elective C/S or one who has had a normal delivery with a healthy infant, but has had a long labour, received an epidural, and episiotomy with sutures.  Category V usually relates to emergency operative delivery, associated medical/obstetric problem, unexpected emergency or stillbirth.

How is midwife time measured?

When the score sheet is completed, a record is made of the length of time that the woman has received care in the delivery suite. During data collection the mean times are recorded by category, thus providing a mean time per category for the calculation of staffing needs. Extra allowances of midwife time are given to women in the three higher need categories thus allowing for the fact that such women or their infant(s) require the attention of more than one midwife at times during their labour.

What other work is recorded in delivery suites?

Experience has shown that there is considerable other work in delivery suites and this consists of;

antenatal cases classified as Category X , Category A1 or A 2,

readmissions, (Category R)  

and midwives escorting mothers and or newborns to another unit for emergency care.

Category X are women who usually self admit, may have early signs of labour, need observation, support and care, but do not progress and go home or might be admitted overnight.

Category A1 are antenatal cases who require some monitoring and possibly intervention, but do not have major problems and may then go home or be admitted to antenatal ward

Category A 2 are antenatal cases with a more serious problem, e.g. premature labour, APH,  raised blood pressure who require intervention and monitoring and will certainly be admitted for further care; or in some cases be transferred to another maternity unit for expert neonatal care. 

More recently we have found gynaecology cases being cared for in delivery suites and this workload is also recorded, as well as the non-viable/registrable births.

How is other midwifery care assessed?

1. Postnatal care; all mothers receive postnatal care in hospital and community. The birth outcome category indicates the degree of need of postnatal care and is used to record the length of stay  in hospital and the midwife hours needed per category for both hospital and community care.

2. Antenatal care in hospital is based upon;   

Recorded midwife time in antenatal clinics and parentcraft sessions   

Classification of the numbers of high and low risk/need antenatal admissions, the length of stay for each group  and the midwife hours needed

Record of any other ward attenders

3. Antenatal care in community is based upon NICE guidelines and midwife hours required. There is some variation of hours depending on whether the community midwife also undertakes the booking and screening process on behalf of the hospital.

BR+ consultants confer with expert groups of midwives to assess and review midwife hours needed for these different aspects of care. 

Are home births included? 

Yes, but the score system is not used as, by definition, those giving birth at home fall within the normal outcome categories. An agreed allowance of midwife time is used for all home births which includes all antenatal and postnatal care. Where a woman who had planned a home birth is transferred to hospital care, the community midwife time for antenatal and postnatal care is used in the staffing calculations.

Are other allowances made before staffing calculations are done?

Yes, allowances are made for management and staff meetings, and for the time spent by midwives in statutory supervision as currently required.

Sickness, study leave and annual leave allowances are also added. These may vary slightly according to the local service standards.

For community midwives provision must be made for the amount of time spent travelling between the homes of clients and clinics etc.

2. Does BR+ always show a need for more staff?

By no means. A Birthrate Plus Study looks at the NEEDS OF THE WOMEN, and the staffing numbers required may or may not be more than current establishment (see Feedback from managers in Bro Morgannwyg Trust)

However, the data enables midwifery managers, obstetricians and trust managers to review demands, care processes and policies, and can often indicate where changes in care practice can reduce demand and/or improve care outcomes ( see feedback from managers in Derby City Hospital). 

Have there been any surprises in looking at the data for different services?

Yes, we have been surprised at the high volume workload arising from Category X admissions.  In some units the numbers are higher than the number of recorded births, which means that some women are admitted several times.

Another issue is the wide variation in cross border cases and it's impact on staffing numbers.

In other services the high percentage of women in the higher need categories has been questioned and has led to clinical care reviews. 

How much data is now available on midwifery staffing needs and can it be used to predict staffing needs when changes in services are planned?

Since 2001 more than 200 maternity services have used BR+ and their data have been stored on a database.  Over time we have been able to track changes in midwifery workload and add to the database to provide a comprehensive profile of maternity services, their activity and workload, and their staffing establishments.

At present we are using the database for England from 2003/2006 as a means of producing ratios of births per w.t.e. midwife to assist units in calculating staff based upon mergers of services etc.

These data have also been used to inform DOH reports.