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
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.

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.

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.

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]