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

OVERVIEW OF THE USE OF BIRTHRATE PLUS® WITHIN MATERNITY SERVICES IN UNITED KINGDOM, EIRE AND AUSTRALIA

May 31 2006

The workforce planning system; Birthrate Plus® (Ball and Washbrook 1996) is based upon
· The principle of one to one care in labour and delivery cited as the standard of care in several government reports
    (Short 1980, Winterton1992, Cumberlege 1993)
· A classification for intrapartum care which uses clinical indicators to assess the level of need of both mother and baby
· Collecting real time data on the length of time a woman required care during labour and delivery and an addition of extra midwife time for those with a high level of need/ intervention or emergency.

The initial development of the intrapartum score system was undertaken in 1986 when blind clinical assessment was used to check the validity of the score system in relation to client records.(Ball 1992, Ball and Washbrook 1996). Since then the methodology has been applied in several hundred maternity services and in each study careful validation procedures are in place to assess the validity of the data produced by comparison with on site clinical records.

The intrapartum classification was then used as a basis for assessing the staffing needs for postnatal care in hospital and community as the outcome for mother and baby has direct impact on postnatal care needs.

In 1992 both the Royal College of Obstetricians and the Royal College of Midwives recommended Birthrate to the House of Commons Select Committee for Maternity Care  as  " a rational basis for assessing staffing needs in delivery units ( see Appendix 2  Towards Safer Childbirth ;RCOG/RCM 1999)

The methodology has also been cited in other publications, notably;
· First Class Delivery (Audit Commission 1997)
· The National Sentinel Caesarean Section Audit Report (RCOG 2001)

Further development enabled other midwifery workload to be assessed via records of antenatal clinics, antenatal admissions and other categories of clients admitted to the delivery suite but who did not give birth of that visit. 

As the methodology was applied in different maternity services it became obvious that there were many services with an extra workload from cross border clients; i.e. those receiving community based ante and postnatal care but who gave birth in another maternity service and are not therefore counted among the births of the "home" maternity service.

The staffing formula used to convert workload to staffing numbers has been updated from time to time to reflect changes in midwife patterns of work and to make allowances for the time spent in supervision of midwives requirements.

Regular updates to the methodology have been produced both by on site experience and the use of “Expert Groups” of senior midwives and by reference to recommendations from NICE etc.

More recently due to changes in the work of midwives it has been necessary to add assessment of workload arising from;
· midwives undertaking neonatal examination previously done by paediatric staff
· in some units the care by midwives of women undergoing abortion/ miscarriage

Validation via application and results
Since 2001 maternity services in the United Kingdom have been assisted by a team of midwives, seconded from the NHS. This work was originally funded by the DOH,  since 2002 individual maternity services had paid for the service. To date a total of 255 maternity services in the United Kingdom have used BR+, with some services repeating the study more than once to assess changes in demand or provision of care.
It has been interesting to find that the methodology has been found to be appropriate in these widely differing maternity services, ranging from units with less than 1000 births per annum to many with 5000 births per annum.

In all cases a detailed report is provided to the local obstetric management team where issues around the method and the results can be discussed and challenged.
In many services it was been found that the current staffing was sufficient, in others a considerable investment in staff was required and in others the data enabled local managers to address areas of inefficient use of resources.
Application outside the United Kingdom

More recently the methodology has been extensively used and validated in Eire.

In 2003 the authors were invited to Geneva to discuss the methodology with the WHO Making Pregnancy Safer Initiative and in 2004 Jean A Ball was commissioned to develop a pilot methodology for assessing the workforce and training needs for Safe Birth Attendants for use in the developing world.

During 2004/05 New South Wales Nurses Association and the NSW Health undertook a study within 13 maternity hospitals to ‘test and adapt’ Birthrate Plus® for use in NSW, as part of the Award entitlment for reasonable workloads for nurses employed in the NSW Public Health Sector culminating in a new Award clause in December 2003. In particular the Award provision for Birthrate Plus can be found in Clause 53 Reasonable Workloads for Nurses, subclause (iii) Reasonable Workload Tool(s) Paragraph (c) Birthrate Plus.  A second study is planned to commence in late 2006, prior to full implementation throughout NSW.

Birthrate Plus Database and providing information to the Department of Health
In 2002 Birthrate Plus authors were invited to provide data on ratios of births/wte midwives for both home and hospital births to the Maternal and Neonatal Workforce Group which formed part of the Department of Health Children’s Taskforce (1993).
The data from each maternity service where the BR+ team have been involved has been collated on a database.
 
At present the collated information includes; data from 74 services which undertook studies in 2003 –2005 and spans based on 258,000 births, with a further 14 services from England to date in the 2006 database.

Thus it provides a unique insight into patterns of maternity care and the various factors which influence staffing needs (See Ball et al 2003).

In 2005 the Birthrate Plus authors were commissioned to provide data and information on staffing issues to the Department of Health National Workforce Review team. As a result it was possible to indicate robust ratios of births/wte midwives for national projection and this link is ongoing.

Also in 2005 Birthrate Plus® authors were commissioned to provide information for the Department of Health Working party on the Recruitment and Retention of Midwives.

More recently the Royal College of Midwives have requested help in assessing ratios of births/midwives for intrapartum care as part of the update of the "Minimum Standards for the Organisation of Labour Wards" (RCOG/RCM 1999).

It should be noted that Birthrate Plus® has never (apart from funds listed below) had any funding for its development, but has produced the database and other developments from the work on site in maternity services. It has however applied strict research criteria to both its ongoing updates and the collation of its database.

In 1992 the DOH Resource Management Team assisted with the costs of producing Birthrate *** (Ball 1992) and in 2001 the DOH Workforce Development Team funded the first 12 months of the work of the BR+ team in assisting maternity services with the application of the workforce planning tool.

References

Department of Health and Social Security 1980 The Second Report from the Social Services Committee on Perinatal and Neonatal Mortality (Short) H.M.S.O. London

Ball J A 1992 BIRTHRATE *** Nuffield Institute for Health University of Leeds

House of Commons 1992 Report of the Health Committee on Maternity Services (Winterton) H.M.S.O. London

Ball J.A. & Washbrook M; 1996 Birthrate Plus; A Framework for Workforce Planning and Decision Making for Midwifery Services.     Books for Midwives Press/ Elsevier Press.

Audit Commission 1997 First Class Delivery; Improving Maternity Services in England and Wales

R.C.O.G. and RCM  1999 Towards Safer Childbirth: Minimum Standards for the Organisation of Labour Wards 1999 RCOG London

R.C.O.G. Clinical Effectiveness Support Unit (2001) The National Sentinel Caesarean Section Audit Report R.C.O.G. RCOG Press London NW1 4RG

Department of Health 1993 Changing Childbirth (Cumberlege Report) H.M.S.O. London

Department of Health 2003 Report to the Department of Health Children’s Taskforce from the Maternal and Neonatal Workforce Group- Jan 03     http://www.doh.gov.uk/maternitywg/report-jan03.pdf

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