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
7.4hrs
III
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 Workload
category
% of
casemix
Number 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
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……..
St Highbury
What’s in & out
In 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 1520%
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
– DGH with >50% in cat IV & V
– DGH with <50% in cat IV & V
– Homebirths & MLUs
• For community activity only
– Antenatal/postnatal
1:38
1:42
1:45
1:35
1:96
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
OU
FMU
Births 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
25,467
Midwives in post
c21,000
Current 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/policypractice/joint-statements-and-reports/