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Rapid Responses: Rapid Responses published:
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Theatre staffing for Caeserean Section
- John Bermingham (12 September 2003)
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Need to review policy for routine induction in women who are post EDD
- Joan M Smithies, The Fairway, Barton on Sea, New Milton. Hants, BH25 7AE (13 September 2003)
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Further thoughts on shortage of midwives
- Stephen J Goldie (16 September 2003)
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The system is broken: do we need more proof?
- Robert A. Knuppel (16 September 2003)
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What about physicians?
- Nikki Lee (17 September 2003)
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Midwifery Shortage - YES, Continuity of Care - NO
- Sally K Tracy, Professor Lesley Page (17 September 2003)
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Time to abandon team midwifery
- Jane Sandall (24 September 2003)
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Midwife staffing in labour wards and quality of care.
- Janet S Tucker, Vanora Hundley, Gillian Penney and Gareth Parry (24 September 2003)
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John Bermingham, Obstetrician&Gynaecologist Waterford Regional Hospital
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The finding of midwifery staff shortage on the floor when a surgical proceedure is underway makes a nonsense of the term 'skill-mix'. Operating room technique and standards are best provided by dedicated theatre staff. One midwife to accompany mother to theatre and assist the paediatric team should be the most that is lost to labour rooms where midwifery skills are needed. Three midwives in theatre is a gross waste of resourses at any time. Competing interests: None declared |
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Joan M Smithies, Consultant Psychiatrist Becton Centre, The Fairway, Barton on Sea, New Milton. Hants, BH25 7AE
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I read this article the day after the planned birth of my daughter's first child at home.,hours before she was due to be admitted to hospital for induction on her twelfth day post EDD.Induction of normal healthy women at 12 days post EDD is presumably recommended to reduce the risks to the baby of postmaturity.Since "near misses"(which may well result in damaged babies and therefore not be "misses" at all)are not recorded, how can professionals, let alone mothers,make an informed decision as to when induction reduces rather than increases the risk to an otherwise normal postmature baby? For my part,my sense of joy and priviledge at being present at my granddaughter's birth was heightened still further by reading this article. Competing interests: None declared |
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Stephen J Goldie, Final year medical student University of Glasgow, G12 8QQ
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The article by Ashcroft, et al is a long over due confirmation of what midwives and obstetric staff have long known: there are not enough midwives working in UK hospitals. More importantly the situation has now reached such a low that it is unsafe and lives may be lost as a result. There are some issues, however, that I feel the article didn’t address or highlight strongly enough. Firstly the reliance upon bank midwives on a daily basis is like using any agency or staff bank: it is an enormous financial drain on NHS resources and a false economy. Bank work may have its plus points in terms of higher hourly rate of pay and flexible hours, but midwives lose out on training and pension schemes etc. This is not good for either the individual or the employer. Secondly, the shortage of midwives is not due to a failure by the universities to keep up with demand and to train new midwives. It is purely a failure by the NHS to provide funding for extra jobs in some areas and to recruit then retain staff in other areas. For example, my partner qualified as a midwife in February 2001 from the University of Paisley, in Scotland. Like many of her colleagues, she was unable to find a job in Paisley, Glasgow or the surrounding area; not even on a midwifery bank. I am sure the midwifery managers in Paisley or Glasgow would have been delighted to employ her and all her classmates; however, they simply do not have the budget to employ sufficient staff. Therefore she was forced to work as an agency health care assistant for six months before taking on a full-time post in Edinburgh. By this point many of those who graduated at the same time had moved to London, Dublin, Jersey or Australia in order to find work, which is a huge drain of skills from Scotland and the NHS as a whole for those leaving the country. Moving to London is the least attractive alternative for newly qualified midwives as the cost of living is so high, while the quality of working conditions and life in general is low. I suspect maternities in the South East of England will be unable to employ enough staff until they can afford to entice them to move and then to stay for the long term. My last point concerning the article is the use of the word ‘client’. The BMJ is a medical journal and although the word ‘patient’ may not be an ideal way to label a woman during a normal delivery, I still think we should avoid describing those under our care as “clients”. Competing interests: None declared |
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Robert A. Knuppel, Professor and Snr. VP for Physician Practice Development Princeton, N.J. 08540
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I read this article expecting different results. The systematic management of midwives appears to reflect the equally inefficient management of physician time. The concept of the fulltime hospital physician providing coverage for L&D should be rapidly adopted. The nurse midwives and the "ob hospitalist" should work as a team to provide their designated services complemented by an adequate theatre staff and neonatal group. The description of near misses would have been avoided almost 90% of the time if you only had a fulltime ob on L&D in the busy hospitals along with the proper support system. Absence of adequate supervision, responsiveness, documentation, and staffing reflects the sytem deficiencies prevalent in the literature for over 3 decades. It is time to change. The changes would introduce efficiency and enhanced surveillance to L&D with little disturbance. Nursemidwives do NOT need to be in the operating theatre. OB hospitalists can cover all emergencies. They may even be trained to provide appropriate early neonatal care. The operating theatre requires the presence of staff and physician, but staffing should allow the nurse midwives to handle the normal delivery and provide communication to the ob hospitalist if complications arise so they can provide team co-management to the emergent situation. At our tertiary care hospital in the US with 6,700 deliveries we provide 24/7 hospitalist coverage to handle oxytocin, epidurals, prenatal evaluations and emergent care. The US needs more nursemidwives and certified nurse practitioners to further reduce cost and enhance efficient triage. The UK needs to look at providing more appropriate staffing and should consider the 24/7 presence of an ob hospitalist to team manage ( with the nurse midwives) and prevent adverse and "near miss" obsteric events. As for the home delivery, there is simply minimal support in the home if the patient becomes "high risk". The "normal obstetric patient" should be managed as a nondiseased patient in the hospital, but if there is an untoward event it is inexcusable to allow the hospital to mimic the home environment. These events are usually emergent and reflect a rapid change in patient status from the "normal" to the unpredictable "high risk". The hospital and staff are there to provide rapid and comprehensive care for the sick and the emergent situation. Failure to do so only equates the hospital with the minimally staffed home environment. Competing interests: None declared |
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Nikki Lee, private practice Elkins Park, PA, USA, 19027
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The authors have done a marvelous job describing the shortfalls of hospitals and a medical system. As a nurse myself, I have witnessed or been part of disasters and near disasters in all areas of care, medicine and surgery as well as in obstetrics. Adverse events and near misses occur during physician practice also. They go along with learning on the job, a corporate approach to medicine where the focus is on money rather than outcomes (particularly true in the USA), and being human. My concern about this article is that the practitioners highlighted are midwives. Midwives are already under incredible siege in the USA, yet the global statistics show that midwives are the best pracitioners for the majority of women.An article such as this, read quickly, could be used to further denigrate midwives. Competing interests: None declared |
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Sally K Tracy, Associate Professor of Midwifery Practice Development UTS, Sydney, Australia, Professor Lesley Page
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Undoubtedly shortages of midwives affect the safety of mothers and babies particularly during labour and birth where the midwife is crucial to effective monitoring and care. The study (1) describes a situation that will be familiar in many parts of the UK (2) and Australia (3) where there is difficulty in recruiting and retaining midwives, and where midwives are often taken away from clinical work by the demands of computer information systems and heavy administrative requirements. However, the system of team midwifery is singled out as a cause of staff shortages and inadequate skills. The concern is expressed that the risks generated by team midwifery systems outweigh the benefits of continuity. The description of team midwifery given is not a continuity of care system. Where systems do provide continuity of care it is more likely that women will have the continuous support of a midwife who follows her through both labour and birth, and it is easier to respond to the peaks and troughs of workload. Evidence from systems where continuity of care has been achieved give no indication of care being unsafe, on the contrary outcomes are generally better than the outcomes of standard fragmented care (4-7). Although we commend the study’s aim to examine the factors associated with a system of care it is misleading to isolate one component in this way. A root cause analysis of ‘near misses’ and adverse events, would take into account all elements of the system: midwives do not practice in isolation. The high rates of intervention in this study make it imperative to evaluate the medical decision making together with the midwifery system in order to fully understand the birthing context. Given the strong evidence that continuity of care reduces the rates of intervention in childbirth and increases the quality of care, (4-7) we do not believe the authors are justified in their statement the ‘risks generated by team midwifery systems outweigh the benefits of attempting to provide continuity of care’. We believe that standard fragmented care is by far the most dangerous system and that some systems, often called team midwifery, set up to increase continuity, do not in fact do so. Professor Lesley Page (UK)
Ref: 1) Ashcroft B, Elstein M, Boreham N, Holm S. Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives. BMJ 2003:327;584-587 2) House of Commons: Health Committee Publications Health - Fourth Report: Provision of Maternity Care June 2003.http://www.parliament.the- stationery-office.co.uk/pa/cm200203/cmselect/cmhealth/464/46402.htm 3) Barclay L, Brodie P, Lane K, Leap N, Reiger K, Tracy S The Final Report of The Australian Midwifery Action Project, AMAP Centre for Family Health and Midwifery, UTS, Sydney 2003 4) Page L, Beake S, Vail A, McCourt C, Hewison J 2001. Clinical outcomes of one-to-one midwifery practice. Br. J of Midwifery 2001;9:700- 706 5) Hodnett, ED. Continuity of caregivers for care during pregnancy and childbirth. [Systematic Review] Cochrane Pregnancy and Childbirth Group Cochrane Database of Systematic Reviews. 1, 2003 6) Benjamin Y, Walsh D, Taub N. A Comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomes. Midwifery 2001;17:234-24 7) Sandall J, Davies J, Warwick C (2001) Evaluation of the Albany Midwifery Practice. Final report. King’s College London UK Competing interests: None declared |
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Jane Sandall, Professor of Midwifery and Women's Health SE1 9NN
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I welcome a study that explores the relationship between the organisation of midwifery and quality of care. The suggestion that team midwifery erodes midwive's labour ward skills and confidence adds to the increasing body of evidence that team midwifery is bad news for women, midwives and the maternity services. In the UK, midwives who work in teams are more likely to suffer burnout, and have less job satisfaction (1), and women receive more fragmented care (2). This is partly because team midwives share a large caseload with diffuse responsibility, have a low degree of control over their work and workload, provide care in a very fragmented pattern and do not often get the opportunity to develop relationships with women throughout the childbearing process. It is hardly surprising that in such a depersonalised system, women sometimes fall through the net, and midwives become demoralised. However, team midwifery is a very different way of organising care to caseload midwifery, where midwives carry responsibility for a small caseload of women, develop a personal relationship with them and attend their birth at home or in hospital. These midwives are not infrequent visitors to the labour ward as was the case Ashcroft’s study. The small number of studies show that caseload midwifery does deliver greater continuity of care (3), and there is some evidence that such continuity of care in complex organisations may be associated with increased patient safety (4). However, when there is no clarification of specific models of care received in research reports, review findings can be confusing, and there is a paucity of randomised studies of caseload midwifery to provide more robust answers to these questions. This does not however negate the need for a stable skilled workforce in hospital labour wards. Too often one part of maternity service provision has been changed (often the community) without looking at the impact on the delivery of care for all women. However the findings of this study do raise questions about what are considered appropriate tasks for all members of the maternity workforce. It would be welcome if all units reviewed how greater support for clerical work can be given to midwives, and we all considered what the potential contribution of midwifery assistants may be. (1)Sandall, J. (1998). "Occupational burnout in midwives: new ways of working and the relationship between organisational factors and psychological health and well being." Risk, Decision and Policy 3(3): 213- 232. (2)Farquar,M. Camilleri-Ferrante,C. Todd,C. (2000) Continuity of care in maternity services: womens views of one team midwifery scheme, Midwifery, 16,1:35-47. (3)McCourt,C. Page,L. Hewison,J. (1998) Evaluation of one-to-one midwifery: Women’s responses to care, Birth, 25,2:798. (4)Cook,RI. Render,M. Woods,DD. (2000) Gaps in the continuity of care and progress on patient safety, BMJ, 320:791-794. Competing interests: None declared |
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Janet S Tucker, Senior Researcher Dugald Baird Centre, Dept. of Obstetrics and Gynaecology, University of Aberdeen, AB25 2ZL., Vanora Hundley, Gillian Penney and Gareth Parry
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Midwife staffing levels in labour wards have been the subject of considerable media interest and therefore the qualitative report by Ashcroft et al exploring midwife availability on outcome indicators is welcome.(1) However, the report is unclear about derivations of definitions used - particularly in crucial areas of defining "minimum staffing levels" and "skill-mix". The standards used to derive midwife ratios of 2:1 for a normal delivery or 3:1 for a high risk delivery of preterm twins are not stated. These ratios appear high and out of step with previously published staffing recommendations.(2-5) Nor is a reason given for disregarding the role of the wider maternity care team in high risk deliveries. These omissions may detract from the credibility of the report to inform service managers. We described labour ward midwife staffing and workload data for 2576 observation periods (6-hourly records) in 23 consultant-led labour wards in Scotland over 4 weeks in September 2000. (6) The prospective Staffing, Workload and Quality of Care Study considered exposure to lower midwife availability during labour on the process of continuous electronic fetal monitoring (CEFM) and on pre-specified, risk-adjusted infant outcomes (7) as part of the Scottish Audit of Prevention and Management of Emergencies in Labour (SAPMEL). (6) We highlight how the number of midwives "required", hence shortfall noted, varies with the assumptions adopted from different expert standards documents or workforce planning tools. Standards we used were assumptions derived from Towards Safer Childbirth, A Framework for Maternity Services in Scotland, Birthrate Plus and the Royal College of Obstetricians and Gynaecologists' (RCOG) discussion document. (2-5) Depending on the standard used, Scottish labour wards had too few midwives to meet staffing requirement between 15% and 38% of the time. (6) When casemix and dependency of women were taken into account, bigger units experience higher workload as well as higher occupancy. (6) We agree that applying too simple an interpretation of standards (e.g. recommending one midwife to one woman in labour) will seriously underestimate the workload effect of high risk women and underestimate the proportion of time that units may not meet their staffing requirement for workload. However, if the ratio is over-inflated, as appears to be the case in the study by Ashcroft et al, (1) then the results may have little applicability to real world scenarios. References 1. Ashcroft B, Elstein M, Boreham N, Holm S. Prospective semi-structured observational study to identify risk attributable to staff deployment, training and updating opportunities for midwives. BMJ 2003; 327: 584-7. 2. Report of a Joint Working Party. Towards Safer Childbirth. Minimum Standards for the Organisation of Labour Wards. Royal College of Obstetricians and Gynaecologists and Royal College of Midwives, London, 1999. 3. Framework for Maternity Services in Scotland. Scottish Executive Health Department, Edinburgh, 2001. 4. Ball JA, Washbrook M. Birthrate plus. Books for Midwives, Cheshire, 1996. 5. Planning for the future as consultants in Obstetrics and Gynaecology. A discussion document. RCOG, London, 1999. 6. Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH) and the Dugald Baird Centre. Scottish Audit of the Prevention and Management of Emergencies in Labour (SAPMEL). SPCERH Publication no. 13, Aberdeen, 2001. 7. Tucker J, Parry G, Penney G, Page M, Hundley V. Is midwife workload associated with quality of process of care (CEFM) and neonatal outcome indicators? A prospective study in consultant-led labour wards in Scotland. Paediatric and Perinatal Epidemiology. 2003; 17: 369-77. (in press). Competing interests: None declared |
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