7 Indicators for safe midwifery staffing

Safe midwifery staffing for maternity settings indicator: outcome measures reported by women in maternity services

Data collection

Local collection could use the following Maternity Services Survey questions developed by the Care Quality Commission which contains a number of questions where the mother's experience of care could be affected by the number of available midwifery staff.

Adequacy of communication with midwifery team

B12. During your pregnancy, did you have a telephone number for a midwife or midwifery team that you could contact?

B14. Thinking about your antenatal care, were you spoken to in a way you could understand?

B15. Thinking about your antenatal care, were you involved enough in decisions about your care?

C12. Did the staff treating and examining you introduce themselves?

C14. If you raised a concern during labour and birth, did you feel that it was taken seriously?

C16. Thinking about your care during labour and birth, were you spoken to in a way you could understand?

C17. Thinking about your care during labour and birth, were you involved enough in decisions about your care?

D3. Thinking about the care you received in hospital after the birth of your baby, were you given the information or explanations you needed?

F1. When you were at home after the birth of your baby, did you have a telephone number for a midwife or midwifery team that you could contact?

Adequacy of meeting mother's needs during labour and birth

C1. At the very start of your labour, did you feel that you were given appropriate advice and support when you contacted a midwife or the hospital?

C2. During your labour, were you able to move around and choose the position that made you most comfortable?

C10. Did you have skin to skin contact (baby naked, directly on your chest or tummy) with your baby shortly after the birth?

C11. If your partner or someone else close to you was involved in your care during labour and birth, were they able to be involved as much as they wanted?

C12. Did the staff treating and examining you introduce themselves?

C13. Were you (and/or your partner or a companion) left aloneby midwives or doctors at a time when it worried you?

C14. If you raised a concern during labour and birth, did you feel that it was taken seriously?

C15. If you used the call button how long did it usually take before you got the help you needed?

C16. Thinking about your care during labour and birth, were you spoken to in a way you could understand?

C17. Thinking about your care during labour and birth, were you involved enough in decisions about your care?

C18. Thinking about your care during labour and birth, were you treated with respect and dignity?

C19. Did you have confidence and trust in the staff caring for you during your labour and birth?

Adequacy of meeting mother's breastfeeding support

E1. During your pregnancy did midwives provide relevant information about feeding your baby?

E4. Were your decisions about how you wanted to feed your baby respected by midwives?

E5. Did you feel that midwives and other health professionals gave you consistent advice about feeding your baby?

E6. Did you feel that midwives and other health professionals gave you active support and encouragement about feeding your baby?

F14. In the 6 weeks after the birth of your baby did you receive help and advice from a midwife or health visitor about feeding your baby?

Adequacy of meeting mother's postnatal needs (postnatal depression and post-traumatic stress disorder) and being seen postnatally by the midwifery team

F6. Would you have liked to have seen a midwife:

  • more often?

  • less often?

  • I saw a midwife as much as I wanted.

F9. Did the midwife or midwives that you saw take your personal circumstances into account when giving you advice?

F10. Did you have confidence and trust in the midwives you saw after going home?

F11. Did a midwife tell you that you would need to arrange a postnatal check-up of your own health with your GP? (Around 4–8 weeks after the birth.)

F12. Did a midwife or health visitor ask you how you were feeling emotionally?

F13. Were you given enough information about your own recovery after the birth?

F16. Were you given enough information about any emotional changes you might experience after the birth?

Local collection of patient experience data could use these questions to provide a more frequent view of performance than possible through annual surveys alone, but please note NHS Surveys asks that local patient surveys avoid overlap with national patient surveys.

Outcome measures

Responsiveness to mother's personal needs.

Data analysis and interpretation

The annual national survey results for your hospital can be compared with previous results from the same trust and with data from other trusts (but be aware that comparison between trusts is subject to variation in expectations of care between different populations). Data from more frequent local data collection, where available, can be compared with previous results from the same service and with data from other parts of your trust.

Safe midwifery staffing for maternity settings indicator: booking appointment within 13 weeks of pregnancy (or sooner)

Definition

A booking appointment is when a woman sees a midwife or a maternity healthcare professional. NICE's guideline on antenatal care recommends that early in pregnancy all women should receive appropriate written information about the likely number; timing and content of antenatal appointments associated with different options of care and be given an opportunity to discuss this schedule with their midwife or doctor. This booking appointment should be within 13 weeks of pregnancy or sooner (ideally by 10 weeks 0 days).

Data collection

Proportion of pregnant women who have seen a midwife or a maternity healthcare professional for health and social care assessments of needs, risk and choices by 13 weeks of pregnancy or sooner.

Numerator: the number in the denominator who have seen a midwife or a maternity healthcare professional for health and social care assessments of needs, risk and choices by13 weeks of pregnancy or sooner.

Denominator: the number of pregnant women.

Data source: Local data collection. This data are currently collated and presented at CCG level through the CCG Outcomes Indicator Set 2014/15 (C1.13). It is also collected through the Maternity Services Data Set.

Outcome measures

Pregnant women that have had a booking appointment by 13 weeks of pregnancy or sooner

Data analysis and interpretation

The number of pregnant women not receiving a booking appointment by 13 weeks of pregnancy or sooner may be sensitive to the number of available midwifery staff. Timely bookings require a multidisciplinary approach, and missed booking appointment rates may also be affected by:

  • patient choice, availability and accessibility

  • availability and accessibility of appropriate facilities

  • availability of all healthcare professionals and support staff

  • knowledge and skills of all healthcare professionals and support staff.

Safe midwifery staffing for maternity settings indicator: breastfeeding

Definition

Breastfeeding is defined as the proportion of mothers who have started or not started breastfeeding and the number and proportion of infants who have been fully, partially or not at all breastfed at 6–8 weeks.

Data collection

a) Proportion of mothers who have initiated breastfeeding.

Numerator: the number in the denominator who initiated breastfeeding.

Denominator: the number of mothers.

Data source: Local data collection. Data can also be collected using NHS England's Maternity and Breastfeeding data return.

b) Proportion of infants who have been fully or partially breastfed at 6–8 weeks.

Numerator: the number in the denominator who have been fully or partially breastfed.

Denominator: the number of infants at 6–8 weeks.

Data source: Local data collection. Data can also be collected using NHS England's Maternity and Breastfeeding data return.

Outcome measures

a) Reported number of mothers who initiate breastfeeding.

b) Reported number of infants who have been fully or partially breastfed at 6–8 weeks.

Data analysis and interpretation

Breastfeeding rates should be compared with previous results from the same maternity service with caution because frequency at maternity service level rates may be too small for significant increases or decreases in these to be apparent.

Although breastfeeding rates may be sensitive to the number of available midwifery staff and support they offer, breastfeeding support needs a multidisciplinary approach, and breastfeeding rates may also be affected by:

  • patient choice

  • availability of appropriate facilities

  • availability of all healthcare professionals and support staff

  • knowledge and skills of all healthcare professionals and support staff.

Safe midwifery staffing for maternity settings indicator: antenatal and postnatal admissions and readmissions within 28 days

Definition

An antenatal admission is defined as a mother who has been admitted to a hospital as an inpatient, before onset of labour, which includes admissions for non-obstetric conditions, planned caesareans, inductions and false labours.

A postnatal admission is any admission to a hospital as an inpatient after childbirth and to the point of the baby's discharge from maternity services.

The reason for admission and date of discharge should be recorded in accordance with the Maternity Services Data Set.

An antenatal or postnatal readmission is defined as taking place within 28 days of the initial antenatal or postnatal admission in accordance with expert consensus.

Data collection

a) Proportion of mothers admitted to a hospital as an inpatient in the antenatal period.

Numerator: the number in the denominator admitted in the antenatal period.

Denominator: the number of mothers admitted to hospital as an inpatient.

Data source: Local data collection. Data can also be collected using the Maternity Services Data Set.

b) Proportion of mothers admitted to a hospital as an inpatient in the postnatal period.

Numerator: the number in the denominator admitted in the postnatal period.

Denominator: the number of mothers admitted to a hospital as an inpatient.

Data source: Local data collection. Data can also be collected using the Maternity Services Data Set.

c) Proportion of mothers readmitted to hospital within 28 days as an inpatient in the antenatal period.

Numerator: the number in the denominator readmitted in the antenatal period

Denominator: thenumber of mothers readmitted to a hospital within 28 days.

Data source: Local data collection.

d) Proportion of mothers readmitted to hospital within 28 days as an inpatient in the postnatal period.

Numerator: the number in the denominator readmitted in the postnatal period

Denominator: thenumber of mothers readmitted to a hospital within 28 days.

Data source: Local data collection.

Outcome measures

a) Reported number of antenatal admissions.

b) Reported number of postnatal admissions.

c) Reported number of antenatal readmissions within 28 days.

d) Reported number of postnatal readmissions within 28 days.

Data analysis and interpretation

Rates of antenatal and postnatal admissions and readmissions within 28 days should be compared with previous results from the same maternity service with caution because frequency at maternity service level rates may be too small for significant increases or decreases in these to be apparent.

Although antenatal and postnatal admission and readmission rates may be sensitive to the number of available midwifery staff, rates of antenatal and postnatal admissions and readmissions need a multidisciplinary approach, and antenatal and postnatal admission and readmission rates may also be affected by:

  • patient choice

  • availability of appropriate facilities

  • availability of all healthcare professionals and support staff

  • knowledge and skills of all healthcare professionals and support staff.

Safe midwifery staffing for maternity settings indicator: incidence of genital tract trauma

Definition

Trauma of the genital tract is defined as when a mother suffers a tear during labour.

Any incidence of genital tract trauma should be recorded and can be further defined in accordance with Maternity Services Data Set to record the type of tear and indicate whether a mother underwent an episiotomy to extend the tear:

  • none

  • labial tear

  • vaginal wall tear

  • perineal tear –first degree (injury to perineal skin only)

  • perineal tear – second degree (injury to perineum involving perineal muscles but not involving the anal sphincter)

  • perineal tear – third degree (partial or complete disruption of the anal sphincter muscles, which may involve either or both the external [EAS] and internal anal sphincter [IAS] muscles)

  • perineal tear – fourth degree (a disruption of the anal sphincter muscles with a breach of the rectal mucosa)

  • episiotomy

  • cervical tear

  • urethral tear

  • clitoral tear

  • anterior incision.

Data collection

Proportion of mothers who experience genital tract trauma during labour.

Numerator: the number in the denominator who have experienced genital tract trauma.

Denominator: the number of mothers who have been in labour.

Data source: Local data collection. Data can also be collected using the Maternity Services Data Set.

Outcome measures

Reported number of genital tract traumas.

Data analysis and interpretation

Rates of genital tract trauma should be compared with previous results from the same maternity service with caution because frequency at maternity service level rates may be too small for significant increases or decreases in these to be apparent. Incident reporting systems may be affected by under-reporting. Periodic local collection of data on whether genital tract traumas are going unreported will identify if changes in reported genital tract trauma rates are true changes in actual genital tract trauma rates or are affected by changes in completeness of reporting.

Although genital tract trauma rates may be sensitive to the number of available midwifery staff, rates of genital tract traumas need a multidisciplinary approach, and genital tract trauma rates may also be affected by:

  • availability of appropriate facilities

  • availability of all healthcare professionals and support staff

  • knowledge and skills of all healthcare professionals and support staff.

Safe midwifery staffing for maternity settings indicator: birth place of choice

Definition

Birth place of choice is defined as the intended place of delivery (type and geographical). The type could be an NHS hospital or a domestic address, and the geographical would be the NHS Trust site code. The intended place of delivery and actual place of delivery should be recorded as well as the reason for the change of place (if applicable) whether that be type or geographical.

Data collection

a) Proportion of births where the intended type of birthplace did not change.

Numerator: the number in the denominator where the intended type of birthplace did not change.

Denominator: the number of births.

Data source: Local data collection. Data can also be collected using the Maternity Services Data Set.

b)Proportion of births where the intended geographical birth place did not change.

Numerator: the number in the denominator where the intended geographical birth place did not change.

Denominator: the number of births.

Data source: Local data collection. Data can also be collected using the Maternity Services Data Set.

Outcome measures

Rates of change in intended place of births.

Data analysis and interpretation

Rates of change in intended place of birth should be compared with previous results from the same maternity service with caution because frequency at maternity service level rates may be too small for significant increases or decreases in these to be apparent.

Although rates of change in intended place of birth may be sensitive to the number of available midwifery staff, rates of change in intended place of birth need a multidisciplinary approach, and genital tract trauma rates may also be affected by:

  • clinical need

  • patient choice

  • availability of appropriate facilities

  • availability of all healthcare professionals and support staff

  • knowledge and skills of all healthcare professionals and support staff.

Safe midwifery staffing for maternity settings indicator: staff-reported measures

Missed breaks

Definition

A missed break occurs when a midwife is unable to take any scheduled break because of lack of time.

Data collection

Proportion of expected breaks for midwives working in maternity that were unable to be taken.

Numerator: the number in the denominator that were unable to be taken.

Denominator: the number of expected breaks for midwives in maternity services.

Data source: Local data collection.

Outcome measures

Proportion of midwives breaks missed because of lack of time.

Midwife overtime

Definition

Midwife overtime includes any extra hours (both paid and unpaid) that a midwife is required to work beyond their contracted hours at either end of their shift.

Data collection

a) Proportion of midwives in maternity services working overtime.

Numerator: the number in the denominator working overtime.

Denominator: the number of midwives in maternity services.

Data source: Local data collection. Data are also collected nationally on the number of staff working extra hours (paid and unpaid) in the NHS National Staff Survey by the Picker Institute.

b) Proportion of midwife hours worked in maternity services that are overtime.

Numerator: the number in the denominator that are overtime.

Denominator: the number of midwife hours worked in maternity services.

Data source: Local data collection. Data are also collected nationally on the number of staff working extra hours (paid and unpaid) in the NHS National Staff Survey by the Picker Institute.

Outcome measures

Staff experience.

Midwife sickness

Definition

Midwife sickness includes any unplanned absence taken by a midwife for their planned shift.

Data collection

a) Proportion of midwives in maternity services who have unplanned absence.

Numerator: the number in the denominator with unplanned absence.

Denominator: the number of midwives in maternity services.

Data source: Local data collection.

b) Proportion of midwife hours that were recorded as midwife sickness.

Numerator: the number in the denominator that are recorded as sickness.

Denominator: the number of midwife hours worked in maternity services.

Data source: Local data collection.

Outcome measures

Staff experience.

Staff morale

Definition

Midwife staff morale includes the proportion of midwives who claim to have job satisfaction.

Data collection

Proportion of midwives in maternity services who report job satisfaction.

Numerator: the number in the denominator who report job satisfaction.

Denominator: the number of midwives in maternity services.

Data source: Local data collection. Data are also collected nationally on the number of staff working extra hours (paid and unpaid) in the NHS National Staff Survey by the Picker Institute.

Outcome measures

a) Midwife job satisfaction.

b) Rates of midwifery staff turnover.

c) Rates of sickness.

Safe midwifery staffing for maternity settings indicator: midwifery establishment measures

Planned, required and available midwifery staff for each shift

Definition

The number of midwife hours which were planned in advance, deemed to be required during that shift and that were actually available.

Data collection

Proportion of total midwife hours for each shift that were planned in advance and that were actually available.

Numerator: the number in the denominator that were actually available.

Denominator: the number of midwife hours for each shift that were planned in advance.

Data source: Local data collection, which could include data collected for the NHS England and the Care Quality Commission joint guidance to trusts on the delivery of the 'Hard Truths' commitments on publishing staffing data regarding nursing, midwifery and care staff levels and more detailed data collection advice since provided by NHS England.

Outcome measures

Deviation between planned and available midwifery staff.

Safe midwifery staffing for maternity settings indicator: the number of women in established labour and the number of midwifery staff available over a specified period, for example 24 hours

Safe midwifery staffing for maternity settings can be indicated by the number of women in established labour and the number of midwifery staff available over a specified time period. This time period can be defined locally, but as an example, a hospital trust may wish to collect this data over 24 hours.

Safe midwifery staffing for maternity settings indicator: high levels and/or ongoing reliance on temporary midwifery staff

Definition

Registered midwives who are working in maternity services who are not contracted with the maternity service.

Data collection

a) Proportion of registered midwives who are working in maternity services who are not contracted with the maternity service.

Numerator: the number in the denominator who are employed on bank contracts.

Denominator: the number of registered midwife shifts per calendar month to work in maternity services.

Data source: Local data collection.

b) Proportion of midwives who are working in maternity services who are on agency contracts.

Numerator: the number in the denominator who are employed on agency contracts.

Denominator: the number of registered midwife shifts per calendar month to work in maternity services.

Data source: Local data collection.

Outcome measures

Expenditure (£) on bank and agency staff per ward.

Safe midwifery staffing for maternity settings indicator: compliance with any mandatory training

Definition

Midwives who are working in maternity services who are compliant with the mandatory training that has been agreed in line with local policy.

Data collection

Proportion of registered midwives working in maternity services who are compliant with all mandatory training.

Numerator: the number in the denominator who are compliant with all mandatory training.

Denominator: the number of registered midwives in maternity service establishment.

Data source: Local data collection.

Outcome measures

% compliance with all mandatory training.