Intended for healthcare professionals


Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives

BMJ 2003; 327 doi: (Published 11 September 2003) Cite this as: BMJ 2003;327:584
  1. Brenda Ashcroft, lecturer (B.Ashcroft{at},
  2. Max Elstein, emeritus professor of obstetrics and gynaecology and reproductive health care2,
  3. Nicholas Boreham, professor of education and employment3,
  4. Soren Holm, professor of clinical bioethics2
  1. 1School of Health Care Professions, University of Salford, Greater Manchester M6 6PU,
  2. 2Institute of Medicine Law and Bioethics, University of Manchester, Manchester,
  3. 3Institute of Education, University of Sterling, Scotland
  1. Correspondence to: B Ashcroft
  • Accepted 15 July 2003


Objective To identify potential risk or mishap in the system of intrapartum care, relating to the deployment of midwives.

Design Prospective semistructured observational study.

Setting Labour wards of seven maternity units in the north west of England.

Participants All midwives working on the labour ward during the observation period in 2000.

Main outcome measure “Latent failures” within the system relating to midwifery staffing levels, deployment, and training or updating opportunities.

Results Despite the exemplary dedication of midwives, potential risk of mishap due to their deployment occurred within the system of care. A shortfall of midwives existed in all seven maternity units and was most acute in the largest units. Six units relied on bank midwives to maintain minimum staffing levels. High risk practices (oxytocin administration and epidural blockades) continued during midwifery shortfalls in all units. Some adverse events and “near misses” were attributable to midwifery shortages in all units, and near misses remained unreported in all units. Uptake of opportunities for training or updating in interpretation of cardiotocographs and obstetric emergency management remained low owing to midwifery shortages in all units. A poor skill mix of midwives occurred at times in all units. In six units midwives spent time away from clinical areas performing clerical duties. In three units team midwifery systems were reported to erode labour ward skills and confidence.

Conclusion Midwives are fundamental components in the system of intrapartum care, and the system cannot operate safely and effectively when the number of midwives is inadequate, midwives are poorly deployed, and they are unable to engage in opportunities for training and updating.


  • Contributors BA did the research, with clinical supervision by ME, academic supervision by NB, and further academic support from SH. BA and ME wrote the paper, with advice from NB and SH. BA is the guarantor.

  • Funding The research received funding from the NHS Executive North West R&D, whose encouragement and advice has been appreciated. Additional funding was from the North West Lancashire Health Authority and the University of Salford. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Competing interests None declared.

  • Ethical approval The North West multicentre research ethics committee approved the study, as did each of the seven trusts' local research ethics committees.

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