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

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)

Associate Professor Sally Tracy (Australia)

6th World Congress of Perinatal Medicine, Osaka, September 13th –
16th,2003

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

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

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