We support safe staffing in the maternity workforce

To ensure that maternity services provide safe, effective, and responsive care to women, service leaders need to understand the clinical needs of the women receiving care – and this is where Birthrate Plus® can help.

Birthrate Plus® is a workforce planning and decision making system for assessing the needs of women for midwifery care throughout pregnancy, labour, and the postnatal period both in hospital and community settings.

The methodology has been in constant use in the UK since 1988. It calculates the required number of midwives to meet all the needs of women and babies in relation to defined standards and models of care, whilst incorporating local workforce planning factors.

Not every woman requires the same level of care nor the same amount of midwifery time during her pregnancy, labour and postnatal period. Using Birthrate Plus® supports service leaders to match their staffing requirement to the clinical needs of women.

It is sensitive and adaptable to changes in national policy which may influence how maternity care is provided such as the provision of continuity of carer.

Birthrate plus is the only midwifery specific tool that has given me the insight and data to model midwifery numbers and skill mix to inform my decision making ensuring that the service is safe and sustainable

Giuseppe Labriola, Director of Midwifery

Basic principles of Workforce planning

  • The methodology is centred upon the Birthrate Plus® Intrapartum Classification System 
  • The score system is based upon clinical indicators of need during labour, birth and post-delivery
  • Each indicator is given a score and the total score is used to place the mother and infant(s) into one of five distinct categories. The birth outcome category also predicts the postnatal care needs for mother and infant
  • The standard of care derived from the Short Report of 1980 (and confirmed by recent NICE publications) is that of a minimum of one to one care from a midwife throughout labour for all women. Therefore, the measure of midwife time needed is based upon the recorded length of time in the delivery suite from admission in established labour, until the mother leaves for post-natal care. Birthrate Plus® provides increased ratios of midwife care for those in the higher need categories where more than one midwife is needed at some stage in the labour process.
  • A further classification is used for other women who require care in the delivery area but do not give birth at that time.
  • Other areas are also included such as alongside midwife units (AMU), triage, maternity assessment/day unit, maternity wards, outpatient clinics, community services midwifery activity including home births and free standing midwife units (FMU).

How it works

To undertake a Birthrate Plus® assessment several specific datasets are collected, and the appropriate method applied to each. The main task is to provide annual births (women delivered) and place, i.e. delivery suite, AMU, home or FMU. The percentage uplift necessary to take account of factors such as staff annual and sick leave is built into the funded establishment

Intrapartum Services:

The casemix is collected from 3 months of births within the obstetric delivery suite. Each woman is assessed, and a Birthrate-Category assigned.

Validation of a sample of data is completed to ensure correct scoring and classification. Using this data, the overall casemix for the unit is ascertained. Births in the AMU are scored and added to the delivery suite data to provide a casemix for community services.

Annual data is gathered on the number of antenatal cases requiring care in the delivery suite, inductions of labour, postnatal readmissions, escorted transfers out and non-viable pregnancies.

If there is a dedicated Triage, this is included and if the activity is seen on the delivery suite instead, the annual number is required.

Maternity Wards:

Antenatal activity: This includes the number of AN antenatal admissions, if any ward attenders and if inductions of labour are carried out on the ward.

Postnatal activity: Annual number of postnatal women generally from delivery suite and some from the AMU, ward attenders, readmissions, NIPE completed by midwives, tongue ties seen by midwives, babies requiring extended care over 72 hours (within the maternity ward area, not NICU).

Outpatient Services:

This includes day unit, maternity assessment unit and usually covers planned activity. A typical weekly profile of hospital based clinics is completed and records details of sessions rather than number of women attending with professional judgement on the appropriate staffing by midwives and support staff.

Community Services activity:

The number of women having antenatal (AN) and/or postnatal (PN) care will include women who have their community AN and PN care within the service, but who have birthed elsewhere (imports) and those who birth within the service but have AN and PN care in another area (exports).

The methodology considers women who are booked in community with adjustments being made if bookings are carried out in hospital clinics. Also, all services have an attrition rate of women who will see a midwife in early pregnancy but either have a pregnancy loss or who move out of area. Furthermore account will be taken of the proportion of women with a significant safeguarding need and additional time added accordingly. Account is also taken of the annual home births and whether midwives go out to BBAs or the women are transferred into hospital. In addition, the time spent travelling within the community is also included and this will show variations between different units due to local geography as well as models of care.

The approach we use ensures all activity that impacts staffing is captured

Specialist midwifery roles:

Each maternity unit will have a requirement for specialist and managerial roles in addition to the clinical roles required. Birthrate Plus® takes this into account and suggests an appropriate number of such non-clinical roles to ensure the safe operational delivery of the service. More info here: Non-clinical-roles document

Our Workforce and Acuity App tools work in unison. Click here to read more about the Acuity App

Further Reading

Here is a list of publications which set out the rationale and development of Birthrate Plus®.

Ball J A (1993). Workload measurement in midwifery In: Alexander J, Levy V, Roch S (Eds) MIdwifery Practice; A Research-Based Approach, Basingstoke, Macmillan

Ball J.A. & Washbrook M; (1996). Birthrate Plus; A Framework for Workforce Planning and Decision Making for Midwifery Services.   Books for Midwives Press/ Elsevier Press.

Ball J A, Bennett B, Washbrook M, Webster F, (2003). Birthrate Plus Programme: a basis for staffing standards? British Journal of Midwifery: Vol11, no. 5 pp 264-266 May 2003

Ball J A, Bennett B, Washbrook M, Webster F, (2003). Birthrate Plus Programme: Factors affecting staffing ratios British Journal of Midwifery: Vol11, no. 6 pp 357-361 June 2003

Ball J A, Bennett B, Washbrook M, Webster F, (2003). Birthrate Plus Programme: Further issues in deciding staffing needs British Journal of Midwifery: Vol 11, no. 7 pp 416-419 July 2003

Ball J A and Washbrook M, (2010). Workforce Planning in Midwifery: an Overview of Eight Years British Journal of Midwifery: Vol 18 No 8 pp527-532 August 2010

Ball J A and Washbrook M, (2010). Birthrate Plus: Using Ratios for Workforce Planning British Journal of Midwifery:  Vol 18 No 11 pp724-730 November 2010

Ball J A and Washbrook M, (2010) Developing a real-time Assessment of Staffing Needs in Delivery suites. British Journal of Midwifery: Vol 18 No 12 pp780-785 December  2010

Ball J A and Washbrook M, (2013). Working with Birthrate Plus® ; Birthrate Plus Consultancy and the RCM 2013

Ball J A, Washbrook M, (2015) Safe Staffing and Midwifery Care; Gathering Data and Learning Lessons; ­ The Health Foundation March 2015