1. Birthrate Plus More than just a number

2. What is it and who can use it? National tool that for any given maternity service calculates the number of clinically active midwives required to deliver a safe high quality service –Individual trusts use it to determine their own staffing needs (individual ratio) –Regions or areas use it for workforce planning, commissioning student numbers (aggregate ratio) –National orgs (DH, RCM) use it to make broad statements about supply and demand (overall ratio)

3. So simply? Number of births _______________ Number of midwives

4. 1.Using BR+ in an individual unit Quantify all activity – how many births, how much antenatal care/postnatal care, how many home births how much additional work: inductions, women not in established labour Distinguish work involved – 5 point categorisation from normal/healthy “simple” maternity care to high risk/complex high degree of support and intervention Collect data over agreed period usually 4/6 months Data analysis makes allowance for time lost (travel, sickness, leave etc)

5. Translating labour ward workload into midwifery hours category% of av casemix Av hours in delivery Midwifery input during labour Total midwifery time required I10.9%6.6 HRS1 wte mw: 1 woman6.6hrs II22.4%7.4 HRS1 wte mw: 1 woman7.4hrs III17.3%9.4 HRS1.2 wte mw: 1 woman11.3hrs IV25.9%10. 7HRS1.3 wte mws: 1 woman13.9hrs V23.5%16.4 HRS1.4 wte mws: 1 woman22.9hrs Cat X122.4%1 hr. Cat 1A11%4 hr. Cat A23%15 hr. Cat R1.5%6 hr. Prostin33%2.5hr2.5 hr. Transfers0.5%8 hr.

6. Example: St Anywhere Trust – 5,200 Women: Labour Ward Workload category% of casemix Number in case mix Av hours in delivery Mw inputMw time required Total Mw hrs.. I10.9%5676.61:16.63,742 II22.4%11657.41:17.48,621 III8999009.41.2:111.310,159 IV25.9%134710.71.3:113.918,723 V23.5%122216.41.4:122.927,983 Cat X122.4%6,3441 hr.6,344 Cat A111%5724 hr.2,288 Cat A23%15615 hr.2,340 Cat R1.5%786 hr.468 Prostin33%17162.5 hr.4290 Transfer0.5%268 hr.208 85,166 hrs..

7. Assessing staffing needs in all other aspects of midwifery care Hospital: antenatal clinics, antenatal admissions, triage, day care postnatal inpatient stays Community: antenatal care, parentcraft education, postnatal care Methodology: Expert Group/Professional Judgement

8. Example: St Anywhere’s community workload for 5200 deliveries Community services Agreed hrs.. per woman St Highbury Booking visit2 hrs..10,400 Antenatal and parentcraft 5.5 hrs..28,600 Postnatal care - simple 5 hrs.. (3120)15,600 Postnatal care complex 8 hrs.. (2080)16,640 Home births17 hrs.. (78)1326

9. Example: St Anywhere’s additional hospital workload Community services Agreed hrs.. per woman St Highbury Antenatal clinicsLocally determined Day unitsLocally determined Ward admissions3hrs, 6 hrs. or 15 hrs. Postnatal wards routine 4hrs or 6 hrs. Postnatal wards complex 17 hrs. or 24 hrs. More……..

10. What’s in & out In Birthrate+ CalculationOut Birthrate+ Calculation All wte clinical midwives wherever they work Non clinical midwifery roles such as managers, clinical governance/risk mws, % of specialist mw or consultant mw time NOT in direct care of women (add 8-10% of midwifery posts) Clinical midwives admin time – allow 5%MSWs (lose 10-15% of midwifery posts Clinical midwives travel time – allow 15- 20% Annual Leave, sickness and study leave etc – allow 17.5-25% Cross border flows, ie women who receive antenatal/postnatal care in 1 trust but deliver in another

11. Result: An individual ratio Ratio is expressed as midwife to births Could be anywhere in the range 1:27 – 1:32 THIS IS ONLY CLINICAL MIDWIVES Depending on –Split between high/low risk women –Amount of time given to travel and other variables –Cross border activity ie antenatal/ postnatal care to women not counted as births

12. Local decisions using ratio How many additional non-clinical midwives (usually between 8-10%) How many midwives can be replaced by MSWs (usually between 10-15%) How to deploy midwives – staffing and service models THIS WILL DETERMINE HOW MANY ACTUAL MIDWIVES ARE EMPLOYED

13. 2. Using BR+ at a regional/planning level – desk top exercise For hospital activity only –Tertiary services 1:38 –DGH with >50% in cat IV & V 1:42 –DGH with <50% in cat IV & V 1:45 –Homebirths & MLUs 1:35 For community activity only –Antenatal/postnatal 1:96

14. Example: Smallcity Trust Wengerville Trust is a medium size obstetric unit with a small free standing midwifery unit. There is a neighbouring Trust nearby and in consequence there is some cross border movement of women OUFMU Births to local residents4669births274 Home births179Number of women booked who deliver elsewhere 420 Number of women booked who deliver elsewhere 435 Number of women from outside the area 394 TOTAL BIRTH ACTIVITY5060274 TOTAL COMMUNITY ACTIVITY5101694

15. Calculating Staffing Using Differentiated Ratios NUMBER OF BIRTHS RATIO APPLIEDWTE STAFFING Obstetric unit births50601:42120.47 Obstetric unit home births 1791:355.11 Obstetric unit community cases 51011:9653.13 Sub total178.71 FMU births2741:358.33 FMU community4201:964.37 Sub total12.7 TOTAL191.41 wte

16. How do you express that? 191.41 wte is a ratio of 1:27.8 across all BIRTHS In the OU the ratio is 1:28.3 across BIRTHS but 1:28.5 across all activity In the FMU the ratio is 1:21.5 across BIRTHS but 1:55 across all activity The amount of antenatal/postnatal care is a significant part of the story

17. Planning midwife numbers Desk top review easily identifies number of midwives required in each trust More robust than simply applying 1 national ratio Local decisions about management time and MSWs Compare requirements with actual staff in post Develop plans for moving from here to there Factor in vacancy rates, retirement predications, local churn Determine number of student midwife commissions required to move from here to there

18. Safety when BR+ is not met? How many women get 1 to 1 care in labour? What % of women are booked by 10/40? What degree of continuity do women receive antenatally and postnatally? Is there a supernumerary ward coordinator on every shift? What specialist roles are funded? How many non-clinical midwifery roles are funded? What are levels of vacancy, turn-over, staff morale and sickness?

19. 3. Using BR+ at a national level ASSUMPTIONS? Average ratio around the country 1:29.5 Birth rate in England around 700,000 Around 96% births in OU Around 8% additional non-clinical midwives required Around 10-15% of clinical midwifery posts can be replaced by MSWs

20. Translates into ? BR+ 2013 Data Assumptions 672,000 births at 1:29.522,780 plus 28,000 at 1:35800 plus 23,580 clinical midwives required (skill mix of 10% MSWs2358) additional 8% non clinical posts1887 Total midwifery workforce25,467 Midwives in postc21,000 Current Shortages4,300

21. Issues going forward National overall ratio changes over time –Are we going with 1:28, 1;29, 1:29.5? Professional consensus on time for community activity probably needs review Professional consensus on MSW time definitely needs review How do we draw attention to the implications of NOT staffing at BR+ recommended ratio? As birth rate goes down will need for midwives? –Not if you take into account increasing complexity

22. Download a copy of the tool http://www.rcm.org.uk/college/policy- practice/joint-statements-and-reports/