The efficient use of the maternity workforce and the implications for safety and quality in maternity care : a population-based, cross-sectional study

Background: The performance of maternity services is seen as a touchstone of whether or not we are delivering high-quality NHS care. Staffing has been identified in numerous reports as being a critical component of safe, effective, user-centred care. There is little evidence regarding the impact of maternity workforce staffing and skill mix on the safety, quality and cost of maternity care in the UK. Objectives: To understand the relationship between organisational factors, maternity workforce staffing and skill mix, cost and indicators of safe and high-quality care. Design and methods: Data included Hospital Episode Statistics (HES) from 143 NHS trusts in England in 2010–11 (656,969 delivery records), NHS Workforce Statistics, England, 2010–11, Care Quality Commission Maternity Survey of women’s experiences 2010 and NHS reference costs 2010/11. Ten indicators were derived from HES data. They included healthy mother and healthy baby outcomes and mode of birth. Adjustments were made for background characteristics and clinical risk. Data were analysed to examine the influence of organisational factors, staffing and costs using multilevel logistic regression models. A production function analysis examined the relationship between staffing, skill mix and output. Results: Outcomes were largely determined by women’s level of clinical risk [based on National Institute for Health and Care Excellence (NICE) guidance], parity and age. The effects of trust size and trust university status were small. Larger trust size reduced the chance of a healthy mother outcome and also reduced the likelihood of a healthy mother/healthy baby dyad outcome, and increased the chances of other childbirth interventions. Increased investment in staff did not necessarily have an effect on the outcome and experience measures chosen, although there was a higher rate of intact perineum and also of delivery with bodily integrity in trusts with greater levels of midwifery staffing. An analysis of the multiplicative effects of parity and clinical risk with the staffing variables was more revealing. Increasing the number of doctors had the greatest impact on outcomes in higher-risk women and increasing the number of midwives had the greatest impact on outcomes in lower-risk women. Although increased numbers of support workers impacted on reducing childbirth interventions in lower-risk women, they also had a negative impact on the healthy mother/healthy baby dyad outcomes in all women. In terms of maximising the capacity of a trust to deliver babies, midwives and support workers were found to be substitutes for each other, as were consultants and other doctors. However, any substitution between staff groups could impact on the quality of care given. Economically speaking, midwives are best used in combination with consultants and other doctors. Conclusions: Staffing levels have positive and negative effects on some outcomes, and deployment of doctors and midwives where they have most beneficial impact is important. Managers may wish to exercise caution in increasing the number of support workers who care for higher-risk women. There also appear to be limited opportunities for role substitution. Future work: Wide variations in outcomes remain after adjustment for sociodemographic and clinical risk, and organisational factors. Further research is required on what may be influencing unexplained variation such as organisational climate and culture, use of NICE guidelines in practice, variation of models of care within trusts and women’s choices. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Mapping midwifery and obstetric units in England

Objective: to describe the configuration of midwifery units, both alongside&free-standing, and obstetric units in England.Design: national survey amongst Heads of Midwifery in English Maternity ServicesSetting: National Health Service (NHS) in EnglandParticipants: English Maternity ServicesMeasurements: descriptive statistics of Alongside Midwifery Units and Free-standing Midwifery Units and Obstetric Units and their annual births/year in English Maternity ServicesFindings: alongside midwifery units have nearly doubled since 2010 (n = 53–97); free-standing midwifery units have increased slightly (n = 58–61). There has been a significant reduction in maternity services without either an alongside or free-standing midwifery unit (75–32). The percentage of all births in midwifery units has trebled, now representing 14% of all births in England. This masks significant differences in percentage of all births in midwifery units between different maternity services with a spread of 4% to 31%.Key conclusions: In some areas of England, women have no access to a local midwifery unit, despite the National Institute for Health&Clinical Excellence (NICE) recommending them as an important place of birth option for low risk women. The numbers of midwifery units have increased significantly in England since 2010 but this growth is almost exclusively in alongside midwifery units. The percentage of women giving birth in midwifery units varies significantly between maternity services suggesting that many midwifery units are underutilised.Implications for practice: Both the availability and utilisation of midwifery units in England could be improved

Timing of singleton births by onset of labour and mode of birth in NHS maternity units in England, 2005-2014: A study of linked birth registration, birth notification, and hospital episode data

BACKGROUND: Maternity care has to be available 24 hours a day, seven days a week. It is known that obstetric intervention can influence the time of birth, but no previous analysis at a national level in England has yet investigated in detail the ways in which the day and time of birth varies by onset of labour and mode of giving birth. METHOD: We linked data from birth registration, birth notification, and Maternity Hospital Episode Statistics and analysed 5,093,615 singleton births in NHS maternity units in England from 2005 to 2014. We used descriptive statistics and negative binomial regression models with harmonic terms to establish how patterns of timing of birth vary by onset of labour, mode of giving birth and gestational age. RESULTS: The timing of birth by time of day and day of the week varies considerably by onset of labour and mode of birth. Spontaneous births after spontaneous onset are more likely to occur between midnight and 6am than at other times of day, and are also slightly more likely on weekdays than at weekends and on public holidays. Elective caesarean births are concentrated onto weekday mornings. Births after induced labours are more likely to occur at hours around midnight on Tuesdays to Saturdays and on days before a public holiday period, than on Sundays, Mondays and during or just after a public holiday. CONCLUSION: The timing of births varies by onset of labour and mode of birth and these patterns have implications for midwifery and medical staffing. Further research is needed to understand the processes behind these findings

Analysing the daily, weekly and yearly cycles of births and their implications for the NHS using linked data

ABSTRACT Objectives This project builds on previous work linking routinely collected data from birth registration, birth notification, death registration and hospital discharges, extending it to six million births in England and Wales from 2005 to 2014. This linkage is creating a new dataset to investigate previously unanswerable questions about variations in time of birth and its outcome which are highly contested in the health service in England and Wales: 1. How do numbers of births vary according to time of day, day of the week and time of year of birth and how does this relate to modes of onset of labour and delivery? 2. How do patterns of birth vary between maternity services in relation to variations in medical and midwifery staffing, patterns of intervention and size of unit? 3. How does the outcome of pregnancy, in terms of mortality and morbidity rates at birth and in the first year of life, vary according to time of birth in relation to gestational age, and intervention in the onset of labour and delivery? 4. Have the patterns changed over the years 2005 to 2014? Approach Routinely collected national datasets for 2005-14 have been linked using patient identifiable data items. They differ in the way data items are recorded. Methods of linkage, quality assurance and data cleaning have been improved, compared with those developed in the original project. This unique approach links clinical data from hospital admissions with more reliable data on birthweight from birth registration and with gestational age and time of birth from birth notification. This enables investigation of the associations between day and time of birth with its outcome. This is also the first study to link mothers’ and babies’ hospital discharge data for England and Wales and to draw on public and patient involvement to include outcome measures specifically designed to be women-centred. Overall, the linkage has created a fuller range of data. Results Results will be available by the time of the conference. Initial results already clearly illustrate differences in timings of birth by time of day and day of the week by mothers’ age, gestational age and birth setting and for singleton and multiple births. Conclusion The study has created a valuable linked dataset that will uniquely enable analyses of associations between timing of birth and its outcome. These results will potentially be able to inform and impact NHS service provision

Rate ratios and confidence intervals for type of day differences by gestational age: Spontaneous onset and birth.

<p>Vertical axes show rate ratios relative to the overall average for each gestational age group within each figure. Error bars show 99% confidence intervals. Likelihood Ratio Test of H₀: Type of day differences do not differ between term, pre-term and post-term births.</p

Average number of term births per hour by type of day: Induced births.

<p>Average number of term births per hour by type of day: Induced births.</p

Rate ratios and confidence intervals for type of day differences by gestational age: Induced onset, spontaneous birth.

<p>Vertical axes show rate ratios relative to the overall average for each gestational age group within each figure. Error bars show 99% confidence intervals. Likelihood Ratio Test of <i>H</i>₀: Type of day differences do not differ between term, pre-term and post-term births.</p

Rate ratios and confidence intervals for type of day differences by gestational age: Spontaneous onset, emergency caesarean.

<p>Vertical axes show rate ratios relative to the overall average for each gestational age group within each figure. Error bars show 99% confidence intervals. Likelihood Ratio Test of <i>H</i>₀: Type of day differences do not differ between term, pre-term and post-term births.</p

Average number of term births per hour by type of day: Caesarean births without prior onset of labour.

<p>Average number of term births per hour by type of day: Caesarean births without prior onset of labour.</p