Birthrate Plus

More than just a number

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)

So simply?

Number of births_______________

Number of midwives

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)

Translating labour ward workload into midwifery hours

category % of av casemix

Av hours in delivery

Midwifery input during labour

Total midwifery time required

I 10.9% 6.6 HRS 1 wte mw: 1 woman 6.6hrs

II 22.4% 7.4 HRS 1 wte mw: 1 woman 7.4hrsIII 17.3% 9.4 HRS 1.2 wte mw: 1 woman 11.3hrs

IV 25.9% 10. 7HRS 1.3 wte mws: 1 woman 13.9hrs

V 23.5% 16.4 HRS 1.4 wte mws: 1 woman 22.9hrs

Cat X 122.4% 1 hr. 1 hr.Cat 1A 11% 4 hr. 4 hr.Cat A2 3% 15 hr. 15 hr.Cat R 1.5% 6 hr. 6 hr.Prostin 33% 2.5hr 2.5 hr.Transfers 0.5% 8 hr. 8 hr.

Example: St Anywhere Trust – 5,200 Women: Labour Ward Workloadcategory % of

casemixNumber in case mix

Av hours in delivery

Mw input Mw time required

Total Mw hrs..

I 10.9% 567 6.6 1:1 6.6 3,742

II 22.4% 1165 7.4 1:1 7.4 8,621

III 899 900 9.4 1.2:1 11.3 10,159

IV 25.9% 1347 10.7 1.3:1 13.9 18,723

V 23.5% 1222 16.4 1.4:1 22.9 27,983

Cat X 122.4% 6,344 1 hr. 6,344

Cat A1 11% 572 4 hr. 2,288

Cat A2 3% 156 15 hr. 2,340

Cat R 1.5% 78 6 hr. 468

Prostin 33% 1716 2.5 hr. 4290

Transfer 0.5% 26 8 hr. 208

85,166 hrs..

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

Example: St Anywhere’s community workload for 5200 deliveries

Community services

Agreed hrs.. per woman

St Highbury

Booking visit 2 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 births 17 hrs.. (78) 1326

Example: St Anywhere’s additional hospital workload

Community services

Agreed hrs.. per woman

St Highbury

Antenatal clinics Locally determined

Day units Locally determined

Ward admissions 3hrs, 6 hrs. or 15 hrs.

Postnatal wards routine

4hrs or 6 hrs.

Postnatal wards complex

17 hrs. or 24 hrs.

More……..

What’s in & outIn Birthrate+ Calculation Out 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

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

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

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

Example: Smallcity TrustWengerville 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

OU FMUBirths to local residents 4669 births 274

Home births 179 Number 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 ACTIVITY 5060 274

TOTAL COMMUNITY ACTIVITY 5101 694

Calculating Staffing Using Differentiated Ratios

NUMBER OF BIRTHS

RATIO APPLIED WTE STAFFING

Obstetric unit births 5060 1:42 120.47

Obstetric unit home births

179 1:35 5.11

Obstetric unit community cases

5101 1:96 53.13

Sub total 178.71

FMU births 274 1:35 8.33

FMU community 420 1:96 4.37

Sub total 12.7

TOTAL 191.41 wte

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

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

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?

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

Translates into ?BR+ 2013 Data Assumptions

672,000 births at 1:29.5 22,780 plus

28,000 at 1:35 800 plus

23,580 clinical midwives required (skill mix of 10% MSWs 2358)

additional 8% non clinical posts 1887

Total midwifery workforce 25,467Midwives in post c21,000Current Shortages 4,300

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

Download a copy of the tool

http://www.rcm.org.uk/college/policy-practice/joint-statements-and-reports/