We support safe staffing in the maternity workforce

Frequently Asked Questions

How has the validity of Birthrate Plus® been determined?

Birthrate Plus® is an evidence-based methodology based on national standards – in particular one-to-one care from a midwife for a woman during labour and delivery, together with the care of the new-born infant(s). It supports maternity services to identify the staffing they need to provide safe care. The methodology is sensitive to local factors, such as case mix and has been in use for over thirty years.

The methodology is based on research published in peer reviewed journals [1] and has been described as the ‘gold standard’ for maternity workforce planning [2]. The methodology was reviewed as part of the post Francis Inquiry safe staffing programme of work led by NHS England. In June 2016 Birthrate Plus® was endorsed by the National Institute for Clinical Excellence (NICE) following a review of the methodology against NICE guidelines on safe midwifery staffing for maternity settings. NICE noted that the resource encourages the use of professional judgement in the final determination of maternity safe staffing levels in line with the safe staffing guideline.

Birthrate Plus® has been used by health departments and academics in a number of countries including Australia, China, Holland and the Republic of Ireland. It is endorsed by Royal College of Midwives and Royal College of Obstetricians and Gynaecologists.

Birthrate Plus®  works with services, Arms-Length Bodies, professional bodies and others to review its methodology and ensure it reflects current practice.


  1. See for example: Ball J A, Bennett B, Washbrook M, Webster F. Birthrate Plus® Programme: Factors affecting staffing ratios. British Journal of Midwifery: Vol.11, no. 6 pp. 357-361 June 2003
  2. Yao, I, Zhu X, and Hong L. (2016). Assessing the midwifery workforce demand: Utilising Birthrate Plus in China. Midwifery 42: 61–66
How does Birthrate Plus® determine time for mandatory training?

Birthrate Plus® doesn’t specify or allocate a set number of hours per midwife for training and we would look to national policy or guidance to specify this.

 There is information available nationally stating the specific components of training that each midwife should complete but there is currently no guidance available nationally which specifies the amount of training time each midwife should receive to complete this training.

 However, each Trust has a locally agreed uplift to cover training, annual leave, sickness etc which ranges from 18-25% and this is included in the Birthrate Plus calculations.

 Some Trusts will have a defined percentage for each element of leave / absence.

For example, Trust A has an uplift of 22% of which there is allocated:

  • 16% annual leave
  • 4% sickness
  • 2% training

 It is important though to note that the training uplift should consider the headcount of staff and not only the wte as every midwife irrespective of the hours they work will usually be required to complete the same amount of training.

 One way for you to consider this locally (if not already known) is to ascertain how many hours of training are required in accordance with the current expectations both locally and nationally for role specific (PROMPT, Fetal monitoring, Safeguarding L3 to name a few) as well as statutory training (Fire, IG, Prevent etc) to understand the impact of this per head count. With this information you will then be able to determine whether the current uplift for training used by your individual Trust is adequate to cover the training requirements of midwives and whether a business case may be required to increase the uplift.

How do you calculate the staffing in units that provide intrapartum care for women who live outside of the community area?

These births are community exports, i.e., the women birth in this unit but have community midwifery care in another Trust location and are excluded from the community midwifery calculation.

A Birthrate Plus assessment would include all of the births which have taken place in a unit irrespective of the initial unit of booking either if it was an unplanned birth in that unit or if care was transferred during the pregnancy due to complexity. The minimum standard of care upon which the methodology is based is 1:1 in labour and each birth is categorised into one of five categories from least risk to most complex. The staffing requirement for Delivery Suite is based on the number of births in each category (as well as other activity including non-viable pregnancies, inductions of labour, women requiring 1:1 care antenatally but not for a birth episode i.e., bleeding, ECV etc) and therefore would allow for the additional birth activity from other units.

This is then also carried through to the PN ward area.

If out of area women attend hospital clinics, day unit or Triage or have an antenatal admission episode, this will also be captured and staffing allocated.

How do you calculate the staffing in units that provide community care for women but who give birth in another Trust?

These births are community imports i.e., those women who birth in one Trust, through choice or need, but have their community midwifery care with another Trust (AN only, PN only or AN and PN).

As part of the assessment the number of women receiving just community care is collected.

This is factored into the staffing establishment required in community and sometimes will mean the cases in community are higher or lower than the births in a Trust.

I’m being asked why we need a different number of midwives compared to another Trust in our LMNS despite having a similar amount of births – how do I explain this this?

Variations in the provision and organisation of care can also result in differing recommendations such as providing minimum staffing models for certain areas (Triage and MLU for example).

Community activity may also vary depending upon the number of women who do not birth in a Trust but receive their community midwifery care from the community midwives.

Other factors also influence the difference such as travel allowance and uplift for training, sickness etc as well as the timing of the assessment, one in 2021 and one in 2022.

Thus, it is not possible to compare the results of one Trust with another directly and we would advise caution if trying to do so.

I’m being asked why we still need the same number of midwives even though our birth rate has dropped – how do I explain this?

In order to provide an accurate determination of the number of midwifery staff required to provide a safe and effective maternity service there are a number of factors which must be taken into account of which the number of births is just one.
Women who access maternity services have a wide range of medical, physical, social and psychological needs some of which will require significant midwifery input in order to ensure their care is given in line with the latest evidence based recommendations. These needs are noted during all stages of the pregnancy journey.
The minimum standard of care during labour is one midwife to one labouring woman, as first described in the Short report (1980), supported by NICE (2015) and further recommended in the Ockenden report (2022). However, some women require the input of more than one midwife during their labour due to complexity or intervention such as fresh eyes review of CTG, checking of medication, second midwife during a complex or multiple birth, all of which need to be accounted for in the establishment setting. Changes to policy and guidance nationally has resulted in an increasing number of women having intervention or additional care and monitoring during pregnancy, labour and following the birth of their baby. There has also been an increase in the number of babies requiring observation during the early postnatal period, all of which increases the midwifery time required to provide (or oversee) the care.

Does Birthrate Plus® include homebirths?

Yes, but the score system is not used as, by definition, those giving birth at home fall within the normal outcome categories. An agreed average allowance of midwife time is used for home births which includes all antenatal, intrapartum, and postnatal care. Where a woman who had planned a home birth is transferred to hospital care, the community midwife time for antenatal and postnatal care is used in the staffing calculations.

What are the principles of Birthrate Plus ®?

Any workforce planning system needs:

  • a method for assessing the workload generated by the number of people cared for and their different levels of care
  • the standard of care to be met
  • a means of recording staff hours required to meet those needs and standards
  • a formula to convert the data into staffing requirements.

Birthrate Plus® is based upon the standard of one-to-one care from a midwife for a woman during labour and delivery, together with the care of the newborn infant(s)

A classification system has been developed which uses clinical indicators to place a mother and baby in one of five outcome categories.

Full details can be found in the manual (Birthrate Plus®; Ball and Washbrook 1996) and other pages on this website. The score system was designed to be easy to complete and has been applied to hundreds of thousands of mothers and babies in UK and abroad. It has remained the same since publication.

A further classification is used for women who receive care in the delivery suite, but who do not give birth during that visit, and this has recently been put onto a separate score sheet in response to changes in practice.

How is Registered Midwives time measured?

When the score sheet is completed, a record is made of the length of time that the woman has received care in the delivery suite. During data collection the mean times are recorded by category, thus providing average hours per category for the calculation of staffing needs. Extra allowances of midwife time are given to women in the three higher need categories thus allowing for the fact that such women or their infant(s) require the attention of more than one midwife at times during their labour.

Allowances are also made for management and staff meetings, training and support to students, personal time and meal breaks. Furthermore sickness, study leave and annual leave allowances are also added. These may vary slightly according to the local service standards.

For community midwives’ provision must be made for the amount of time spent travelling between the homes of clients, clinics and community bases.

My Birthrate Plus report states that my community ratio is 96:1 WTE – what does this mean?

The ratio, which is individual to each unit, is used to determine the allocation of the WTE for community rather than what each individual midwife would have at any given time. It will include all women who receive community midwifery care and is calculated to incorporate women having AN and PN care, AN care only and PN care only. It will also consider all community imports.

It is an establishment setting ratio and not a deployment ratio.

In the example given in the question, for every 96 women needing community midwifery care there needs to be 1 WTE midwife

There will be fluctuations in caseload numbers between midwives depending upon the complexity of women i.e., Vulnerable. Low risk, social deprivation etc – some midwives will have more than the “ratio” and some will have less.

However, knowing the number of women in the caseload of each midwife at any given time, understanding the caseloads and their complexity is vital for the safe running of the community service to ensure individual midwives are not over-stretched or under-utilised.

How do I calculate the worked midwife to birth ratio?
Download a PDF showing the method to calculate the worked midwife to birth ratio
I have forgotten my password - how do I reset it?
I have lost internet access can I still use the App ?
Yes, download the downtime documents:

Complete and then send electronic copies of the completed sheets to [email protected]

What technology is needed to use the App?

The technology we use is detailed in this factsheet

When entering data to the App, can this be done retrospectively?

On the intrapartum part of the App, there is an hour’s window for entering data: 30 mins before and 30 mins after the scheduled time. If the Coordinator is unable to enter data within this timeframe due to being busy, there is an ‘additional entry’ tab which will enable them to enter data. This data entry does not contribute to the overall compliance but the data will be recorded.

On the ward tool there is a window for data entry 30 minutes before the scheduled entry time and 60 minutes afterwards. There is more information regarding how to use the acuity tool in the “support and training” section of this website. This is password protected. Please contact us if you are a current user and would like access to this section.

Does Birthrate Plus® always show that there is a need for more staff?

By no means. A Birthrate Plus® Study looks at the needs of the woman and the staffing numbers required may or may not be more than current establishment.

However, the data enables midwifery managers, obstetricians, and trust managers to review demands, care processes and policies, and can often indicate where changes in care practice can reduce demand and/or improve care.

Should I include the Coordinator when adding the number of midwives in the intrapartum app

The methodology both in the tool and the workforce assessment takes account of the coordinator, and they should be included – whilst they are supernumerary they do undertake some clinical care such as fresh eyes, medication checks, supporting in some births etc.


If at any point they are not supernumerary (as defined in the CNST MIS guidance) this should be recorded as a red flag – we can also split this red flag into 2 separate flags to support the data capture for CNST – those times when the coordinator is not supernumerary but is not providing 1:1 care (perhaps caring for a PN woman waiting to go to the ward) and those times when they are not supernumerary and are providing 1:1 care ( a woman in labour or high risk AN woman).


They would still be considered supernumerary when providing some other elements of clinical care as described above (fresh eyes etc) but lose supernumerary status should they be the sole carer for a woman irrespective of whether she needs 1:1 care or not.

What about Maternity Support Workers?

Birthrate Plus® recognises that not all the clinical work in maternity services needs to be undertaken by midwives and that by enriching skill mix to include maternity support workers (MSWs), nursery nurses, general nurses and others, midwifery time and expertise can be better focused and targeted. Individual units will make their own judgement
about the proportion of midwifery time that can safely be replaced by other roles. As a guide Birthrate Plus® suggests factoring in up to 10% of midwifery hours to be provided by appropriately educated and competent MSWs. Full implementation of the Health Education England Competency, Education and Career Development Framework and associated apprenticeship standards provides assurance that MSWs are appropriately educated and competent. MSWs primarily contribute to postnatal (ward and community) care. Exact skill mix ratios will depend on local circumstance. Support staff who assist midwives but do not provide direct care such as clerical staff and housekeepers should not be included in any ratio.


Enquiring from outside the UK? Email us with your questions: [email protected]