An Overview of the History and Development of Birthrate Plus® Workforce Planning Methodology

This section will explain the methodology of the workforce planning system and how it has been developed by extensive use within the NHS and abroad.

Birthrate Plus®. Is a method for assessing the needs of women for midwifery care throughout pregnancy, labour and the postnatal period in both hospital and community settings. From that data it is possible to calculate the required numbers of midwives to meet all of those needs in relation to defined standards and models of care and to local workforce planning needs, holiday and travel allowances etc.

The methodology is founded upon;

Women in delivery suite

the unique Birthrate Plus ® Intrapartum Classification system. This is based upon clinical indicators of need during labour, birth and post-delivery. Each indicator is given a score and the total score is used to place the mother and infant(s) into one of five distinct categories. The birth outcome category also predicts the postnatal care needs for mother and infant. A further classification is used for other women who require care in the delivery area but do not give birth at that time.

The standard of care derived from the Short Report of 1980 (and confirmed by recent NICE publications) is that of a minimum of one to one care from a midwife throughout labour for all women. Therefore, the measure of midwife time needed is based upon the recorded length of time in the delivery suite from admission in established labour until the mother leaves for post-natal care. Birthrate Plus provides increased ratios of midwife care for those in the higher need categories where more than one midwife is needed at some stage in the labour process.

This original work and later developments have been produced by independent work, which was not funded by any health organisation or government body, although some small development funds were received from the Department of Health to help towards the publication costs of Birthrate *** 1992, and in 2001 to enable a small number of health authorities to apply the methodology in their services under the leadership of Marie Washbrook.

Birthrate (later to become Birthrate Plus) was was first reported at the Research and the Midwife Conference of 1988(unpublished). This was followed by the publication of Birthrate *** A method of outcome review and manpower planning in the delivery suite; Ball J A 1992 Nuffield Institute for Health University of Leeds.

Further application of the methodology within the NHS together with consultation with other midwives enabled the system to be extended to all other aspects of midwifery care in hospital and community, and these additions led to the publication of Birthrate Plus; A framework for workforce planning and decision making for midwifery services. Ball and Washbrook 1996, Books for Midwives Press. In 2000 Books for Midwives Press was sold to Butterworth and Heinemann which is an imprint of Elsevier Ltd. In September 2009 the copyright of Birthrate Plus and all the associated rights were transferred back from Elsevier Ltd to Jean A Ball and Marie Washbrook.

Trademarks The name Birthrate Plus® was granted a United Kingdom trademark from September 2005 and this was followed by Irish, International and Australian Trademarks from 2007. In all cases the owners cited are Jean A Ball and Marie Washbrook.

Extensive use and development of the methodology among maternity services

From 2001 onwards, BR+ has been used in almost all maternity services in England, Wales and Northern Ireland and also in Southern Ireland and Australia. During this time, it has been updated in the light of NICE guidelines and changes in midwifery practice, but apart from a minor adjustment early in 1993, the intrapartum classification system has proved to be robust in all circumstances and provides a framework for assessing staffing needs in all areas of maternity care. In the following areas, staff time is based upon the standards of care required by Expert Group approach which includes those listed in NICE guidelines, research where available together with professional judgement.

Postnatal care; the intrapartum category is a predictor of the length of stay and type of care required in the puerperium. Based upon Nice guidelines for postnatal care agreed midwife hours related to maternal need provide planning basis for hospital; and subsequent community care. Most women with normal outcome go home within 24 hours of giving birth, other need a longer stay. Further allowances of midwife time are built in for women/infants needing extra care and for specific midwife roles such as neonatal examination of the newborn.

Antenatal care; a) community midwives provide the bulk of antenatal care for women expected to have a normal pregnancy etc. Again using Nice guidelines as the standard, agreed hours of midwife time are allocated for antenatal clinics, visits and parent education, etc. This often includes making the booking with the hospital and arranging screening procedures. b) Hospital antenatal care is calculated by assessing the hours of midwife time required to staff all the clinics and classes taking place. Midwife hours for Inpatient antenatal care is based upon level of client need with consideration of length of stay.

Total staffing summary The Birthrate Plus Workforce Planning system provides each maternity service with a detailed breakdown of the number of midwives required for each area of service in both hospital and community. It also provides each service with its own individual ratios of hospital births per whole time equivalent midwife and the number of cases and home births per wte community midwife. This allows each service to apply its own allowances for holiday, sickness and study leave and for time spent in travel by community staff.

Analysis of Data A database of the results for each services was compiled which, combined with the work of Marie in each individual service, enabled further understanding of issues that impact on staffing needs. It also indicates how the judicial use of ratios of births per midwife might be used for national planning together with separate ratios of births per hospital midwife and cases per community midwife.

Lessons learned and anomalies exposed

During the application and analysis of workforce planning studies in so many and varied services a number of factors and potential pitfalls have been exposed which have led to further understanding of the complexity of demand and patterns of work upon midwifery staffing needs. These are summarised below. Note; more details on these issues can be found in the list of publications at the end of this section.

Other factors affecting workload and staffing needs.

Extra workload in delivery suite

Most services also care for large numbers of women in the delivery suite who do not give birth during that episode of care. Of these the largest component are the Cat X; i.e. women who attend the hospital, not sure if they are in labour or not/ feeling unwell or anxious who need care and assurance and then either go home or may be admitted to a ward overnight. The other group are antenatal women presenting with some need for monitoring/ assessment who will remain on labour ward and then go home or be admitted for further care.   The scale of this extra workload was largely unrecorded until Birthrate Plus, and presents not only extra demand but can divert midwife time from labouring women. Identifying this workload has enabled services to make other arrangements for the care of Cat X clients.

Impact of cross border workload on staffing needs for each service.
Community midwives provide the bulk of antenatal and postnatal care of all women booked for hospital birth in their area, but these women may give birth in a number of different hospitals. Although this cross–border activity can vary a great deal it is a significant factor in strategic planning and has two main effects. Some Health Trusts may need 10 or more full time community midwives to provide care to women giving birth in external hospitals over and above those needed for their own clients. The opposite effect is to reduce the total number of community midwives required by a Trust where the hospital discharges a number of its clients to other Health Trusts. For example, one Hospital providing specialist care to a wide area found that 50% of all its births were women who received their community care elsewhere. Therefore, staffing should be assessed separately for hospital and community staff. This also highlights the danger of using staffing ratios based on hospital births as any form of performance indicator.

Needs of units with less than 2000 births In Units caring for less than 2000 births per annum the staffing generated by workload alone may not provide safe staffing over 24-hour period. In that case, staffing is calculated using Birthrate Plus methodology and then additional staffing included based upon the numbers of midwives per shift needed to provide the desired duty of care for their clients.

Other factors in determining staffing needs Midwives provide specialist services to women with particular needs, they also undertake duties which were previously the responsibility of junior doctors. In the community midwives are very involved with safeguarding and related public health matters. This workload is calculated separately to that of the main study.

Skill Mix. Birthrate Plus does not specify the skill mix but provides a framework which enables local managers to determine where midwife support workers and other staff might best be used.

Further Development of the BR+ methodology for Real Time Assessment of Demand A detailed workforce planning study provides invaluable insight into the demands made on individual services, but the data provides a staffing establishment based on annual data. The question then arises of how to manage the deployment of staff to match the fluctuating level of demand in both numbers and intensity of need.

In response and working closely with colleagues in a number of different services we have now created a) the Intrapartum Acuity system and b) are currently piloting a Ward Acuity system.

Intrapartum Acuity:   The score system was adapted to provide a prospective assessment of client needs during their episode of care in delivery suite and/or co-located birth centre, which can be recorded on a 2/3/4 hourly basis and is being used to enable managers to ensure safety for clients during this period.

Ward Acuity: This has been a more complex task but after working with a number of services is now in its final piloting stage

Further Reading

A number of journal articles have been published which explore the work of Birthrate Plus over the years and these are listed below;

Ball J A and Washbrook M;  Workforce Planning in Midwifery: an Overview of Eight Years British J Midwifery August 2010 Vol 18 No 8 pp527-532

Ball J A and Washbrook M;   Developing a real-time Assessment of Staffing Needs in Delivery suites British J Midwifery December 2010 Vol 18 No 12 pp780-785

Ball J A, Washbrook M, RCM; Working with Birthrate Plus  Royal College of Midwives London 2013

On Line; Ball J A, Washbrook M, 2015 Safe Staffing and Midwifery Care; Gathering Data and Learning Lessons; ­ The Health Foundation March 2015