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

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