Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The recommendations in this guideline cover all aspects of care provided by a midwife employed to provide NHS-funded maternity care in:

  • all maternity services (for example, clinics, home visits, maternity units)

  • all settings where maternity care is provided (for example, home, community, free-standing and alongside midwifery-led units, hospitals including obstetric units, day assessment units, and fetal and maternal medicine services)

  • the whole maternity pathway (pre-conception, antenatal, intrapartum and postnatal).

Recommendations in section 1.1 focus on the responsibilities that organisations have and the actions they should take to support safe midwifery staffing requirements in all maternity settings.

Recommendations in section 1.2 describe the process and the factors to consider when setting midwifery staffing establishments. The process described in this section could also be used as the specification for a toolkit for setting the midwifery staffing establishment.

Recommendations in section 1.3 are about ensuring that maternity services can respond to increased demand for midwifery staff and to differences between the number of midwives needed and the numbers available.

Recommendations in section 1.4 are about monitoring whether safe midwifery staffing requirements are being met. This includes recommendations to review midwifery staffing establishments and adjust them if necessary.

1.1 Organisational requirements

These recommendations are for commissioners, trust boards and senior management.

Focus on care for women and babies

1.1.1

Ensure women, babies and their families receive the midwifery care they need, including care from specialist and consultant midwives, in all:

  • maternity services (for example, pre-conception, antenatal, intrapartum and postnatal services, clinics, home visits and maternity units)

  • settings where maternity care is provided (for example, home, community, free-standing and alongside midwifery-led units, hospitals including obstetric units, day assessment units, and fetal and maternal medicine services).

1.1.2

This should be regardless of the time of the day or the day of the week.

Accountability for midwifery staffing establishments

1.1.3

Develop procedures to ensure that a systematic process is used to set the midwifery staffing establishment (see recommendation 1.2.2) to maintain continuity of maternity services and to provide safe care at all times to women and babies in all settings. The board should ensure that the budget for maternity services covers the required midwifery staffing establishment for all settings.

1.1.4

Ensure that maternity services have the capacity to do the following:

  • Deliver all pre-conception, antenatal, intrapartum and postnatal care needed by women and babies.

  • Provide midwifery staff to cover all the midwifery roles needed for each maternity service, including coordination and oversight of each service.

  • Allow for locally agreed midwifery skill mixes (for example, specialist and consultant midwives, practice development midwives).

  • Provide a woman in established labour with supportive one-to-one care.

  • Provide other locally agreed staffing ratios.

  • Allow for:

    • uplift (which may include consideration of annual leave, maternity leave, paternity leave, study leave including mandatory training and continuing professional development, special leave, and sickness absence)

    • time for midwives to give and receive supervision in line with professional guidance

    • ability to deal with fluctuations in demand (such as planned and unplanned admissions and transfers, and daily variations in midwifery requirements for intrapartum care).

1.1.5

Ensure that maternity services use local records of predicted midwifery requirements and variations in demand for midwifery staff to help plan ahead and respond to anticipated changes (for example, local demographic changes and women's preferences for place of care).

1.1.6

Develop procedures to ensure that the midwifery staffing establishment is developed by midwives with training and experience in setting staffing establishments. Procedures should ensure that the midwifery staffing establishment is approved by the head of midwifery and the director of nursing and midwifery or chief nurse.

1.1.7

Ensure a senior midwife or another responsible person is accountable for the midwife rosters that are developed from the midwifery staffing establishment.

1.1.8

Ensure that there are enough midwives with the experience and training to assess the differences in the number and skill mix of midwives needed and number of midwives available for each shift (see section 1.3).

Organisational level actions to enable responsiveness to variation in demand for maternity services

1.1.9

Develop escalation plans to address demand for maternity services and variation in the risks and needs of women and babies in the service.

1.1.10

Develop escalation plans in collaboration with midwives who are responsible for determining midwifery staffing requirements at unit or departmental level.

1.1.11

Ensure that escalation plans contain actions to address unexpected variation in demand for maternity services and midwifery needs. These plans could include:

  • sourcing extra staff such as using:

  • redistributing the midwifery workload to other suitably trained and competent staff

  • redeploying midwives to and from other areas of care

  • rescheduling non-urgent work.

    Action in relation to these plans must not cause midwifery red flag events (see box 3: midwifery red flag events) to occur in other areas. Only consider service cancellations or closures as a last resort.

1.1.12

Actions within the escalation plans related to midwifery staffing should be approved by the head of midwifery and director of nursing and midwifery or chief nurse.

Monitoring the adequacy of midwifery staffing establishment

1.1.13

Review the midwifery staffing establishment at board level at least every 6 months, ensuring the review includes analysis of:

1.1.14

Review the midwifery staffing establishment at board level more often than every 6 months if the head of midwifery or director of nursing and midwifery identifies that this is needed. For example if:

  • the implementation of escalation plans is increasing

  • local services are reconfigured

  • midwifery staffing deficits occur frequently

  • the quality of the service has deteriorated as indicated by complaints, midwifery red flag events or other quality measures

  • staff absenteeism is increasing

  • there is unexpected increase or decrease in demand for maternity services.

1.1.15

Change the midwifery staffing establishment if the review indicates this is needed and consider flexible approaches such as adapting shifts and amending assigned location.

Monitoring and responding to changes

1.1.16

Ensure that maternity services have procedures in place for monitoring and responding to unexpected changes in midwifery staffing requirements.

1.1.17

Ensure maternity services have procedures in place for:

  • informing members of staff, women, family members and carers about what midwifery red flag events (see box 3) are and how to report them

  • the registered midwife in charge of the shift or service to take appropriate action in relation to midwifery red flag events

  • recording and monitoring midwifery red flag events as part of exception reporting.

1.1.18

Involve midwives in developing and maintaining midwifery staffing policies and governance, including escalation planning.

1.1.19

Ensure that actions in relation to midwifery red flag events or unexpected changes in midwifery staffing requirements:

  • take account of women and babies who need extra support from a midwife

  • do not cause midwifery red flag events to occur in other areas of the maternity service.

Promoting staff training, education and time for indirect care activities

1.1.20

Ensure that midwives have time for:

  • participating in continuing professional development, statutory and mandatory training, and supervision

  • receiving training, mentoring and preceptorship

  • providing training and mentoring for student midwives or other maternity service staff

  • supervising and assessing the competencies of other midwives and non-midwifery staff (including maternity support workers)

  • taking part in indirect care activities such as clinical governance, safeguarding, administration and liaison with other professionals

  • setting the midwifery staffing establishment

  • assessing the midwifery requirements for each day or shift, including collecting and analysing data.

1.2 Setting the midwifery staffing establishment

These recommendations are for registered midwives (or other authorised people) who are responsible for determining the midwifery staffing establishment.

1.2.1

Determine the midwifery staffing establishment for each maternity service (for example, pre‑conception, antenatal, intrapartum and postnatal services) at least every 6 months.

1.2.2

Undertake a systematic process to calculate the midwifery staffing establishment. The process (or parts of the process) could be supported by a NICE-endorsed toolkit (if available). The process should contain the following components:

  • Use historical data about the number and care needs of women who have accessed maternity services over a sample period (for example, the past 12 months or longer).

  • Estimate the total maternity care hours needed over the sample period based on a risk categorisation of women and babies in the service. This should consider the following:

    • risk factors, acuity and dependency (see box 1 [A] for examples)

    • the estimated time taken to perform all routine maternity care activities (see box 2 part A for examples)

    • the estimated time taken to perform additional activities (see box 2 part B for examples).

  • Divide the total number of maternity care hours by the number of women in the time period to determine the historical average maternity care hours needed per woman.

  • Use data on the number of women who are currently accessing the maternity service and the trend in new bookings to predict the number of women in the service in the next 6 months.

  • Multiply the predicted number of women in the service over the next 6 months by the historical average maternity care hours needed per woman to determine the predicted total maternity care hours needed over the next 6 months.

  • From the total predicted maternity care hours, identify the hours of midwife time and skill mix to deliver the maternity care activities that are required. Take account of:

    • environmental factors including local service configuration (see box 1 [B] for examples)

    • the range of staff available, such as maternity support workers, registered nurses or GPs, and the activities that can be safely delegated to or provided by them (see box 1 [C] for examples).

  • Allow for the following:

    • one-to-one care during established labour (unless already accounted for in the historical data)

    • more than one-to-one care during established labour if circumstances require it (unless already accounted for in the historical data)

    • any staffing ratios for other stages of care that have been developed locally depending on the local service configuration and the needs of individual women and babies

    • the locally defined rate of uplift (for example, to allow for annual leave, maternity leave, paternity leave, study leave, special leave and sickness absence).

  • Divide the total midwife hours by 26 to give the average number of midwife hours needed per week over the next 6 months.

  • Divide the weekly average by the number of hours for a full time working week to determine the number of whole time equivalents needed for the midwife establishment over the next 6 months.

  • Convert the number of whole time equivalents into the annual midwife establishment.

    Figure 1: systematic process to calculate the midwifery staffing establishment, summarises this process.

1.2.3

Base the number of whole-time equivalents on registered midwives, and do not include the following in the calculations:

  • registered midwives undertaking a Local Supervising Authority Programme

  • registered midwives with supernumerary status (this may include newly qualified midwives, or midwives returning to practice)

  • student midwives

  • the proportion of time specialist and consultant midwives who are part of the establishment spend delivering contracted specialist work (for example, specialist midwives in bereavement roles)

  • the proportion of time midwives who are part of the establishment spend coordinating a service, for example the labour ward.

1.2.4

Use professional judgement at each stage of the calculation and when checking the calculations for the midwifery staffing establishment.

1.2.5

Base the midwife roster on the midwifery staffing establishment calculations, taking into account any predictable peaks in activity, and risk categorisation of women and babies (for example, during the day when midwife activities are likely to be planned, or for a service dealing with higher risk category women and babies).

Figure 1: systematic process to calculate the midwifery staffing establishment

Box 1 Examples of factors to consider when assessing maternity care needs

A Risk, acuity and dependency of each woman and baby

Risk:

  • Age

  • Cardiovascular

  • Complications (previous)

  • Current pregnancy

  • Disabilities

  • Endocrinological

  • Fetal

  • Gastrointestinal

  • Gynaecological

  • Haematological

  • Immunological

  • Infective

  • Learning difficulties

  • Neurological

  • Obesity

  • Psychiatric

  • Renal

  • Respiratory

  • Skeletal

  • Substance use

Antenatal acuity/dependency

  • No significant intervention required

  • Induction of labour

  • Requires specialised care

  • Requires treatment

Intrapartum acuity/dependency

  • Apgar score

  • Birth trauma

  • Birth weight

  • Caesarean section

  • Death

  • Duration of labour

  • Gestation

  • Operative vaginal delivery

  • Post-delivery emergency

Postnatal acuity/dependency

  • Moderate dependency

  • Readmission

  • Straight forward

  • Transfer out

B Environmental factors

Local service configuration or models of care, for example:

  • Consultant-led care

  • Midwife-led care

  • Shared care

Unit/department layout, for example:

  • Number of beds, units, bays (and distance between them)

Availability of and proximity to related services, for example:

  • Breastfeeding clinics

  • Fetal medicine department

  • Maternal medicine department

  • Other specialist centres

Local geography and availability of neighbouring maternity services, for example:

  • Travel time between services

C Staffing factors

Availability of non-midwifery staff, for example:

  • Allied health professionals (e.g. sonographers)

  • Clerical staff and data inputters

  • GPs

  • Maternity support workers

  • Medical consultants

  • Nursery nurses

  • Registered nurses

  • Temporary staff

Box 2 Examples of maternity care activities that affect midwifery staffing

Part A: Examples of routine care activities

Antenatal

  • Booking appointment

  • Antenatal appointment (including assessment, education, lifestyle advice and fetal monitoring)

  • Antenatal screening and tests (e.g. fetal heart auscultation/scan)

Intrapartum

  • Routine intrapartum care (including assessment, support, monitoring, management)

  • One-to-one care (during established labour)

Postnatal

  • Routine postnatal care (including observations, hygiene, discharge planning)

  • Newborn assessment/ examination/ screening/vaccination (e.g. heel prick, hearing, vitamin K administration)

  • Postnatal appointment (including assessment, education, advice and infant monitoring)

All stages of care

  • Routine administration (including care planning, case notes, referrals)

  • Checking/ordering/ chasing (e.g. preparing medication, checking specialist equipment, checking blood results)

  • Transfers

Part B: Examples of activities that may need additional time

Antenatal

  • Admission to labour ward or day unit

  • Providing additional antenatal screening and tests (e.g. fetal anomaly)

  • Providing antenatal vaccinations (e.g. flu)

Intrapartum

  • Additional monitoring/interventions (e.g. cannula, epidural, fetal monitoring, induction of labour)

  • Managing complications (e.g. managing fetal distress, complicated birth)

  • Specialising/high dependency/intensive care

Postnatal

  • Maternal or neonatal death (including arrangements after death and support for relatives and carers)

  • Managing complications (e.g. postpartum haemorrhage, difficulty establishing infant feeding)

All stages of care

  • Case conferences

  • Additional time for the following:

    • Consideration of preferred place of birth (e.g. home birth)

    • Providing care for women needing specialist input (e.g. female genital mutilation)

    • Managing specific clinical conditions (e.g. diabetes)

  • Managing specific social issues (e.g. child protection, safeguarding)

  • Communicating with women and carers/family including those with sensory impairment or language difficulties

  • Providing additional education, training and emotional support (e.g. new medication, equipment or diagnosis in baby/mother)

  • Coordination of service, or liaison with multidisciplinary team or other services

  • Escorts/transitional care

Note: these activities are only a guide and there may be other activities that could also be considered.

1.3 Assessing differences in the number and skill mix of midwives needed and the number of midwives available

These recommendations are for registered midwives in charge of assessing the number of midwives needed on a day-to-day basis.

1.3.1

As a minimum, assess the differences between the number of midwives needed and the number of midwives available for each maternity service in all settings:

  • once before the start of the service (for example, in antenatal or postnatal clinics) or the start of the day (for example, for community visits), or

  • once before the start of each shift (for example, in hospital wards).

    This assessment could be facilitated by using a toolkit endorsed by NICE.

1.3.2

During the service period or shift reassess differences between the midwifery staff needed and the number available when:

  • there is unexpected variation in demand for maternity services or midwifery care (for example, if there is an unexpected increase in the number of women in established labour)

  • there is unplanned staff absence during the shift or service

  • women and babies need extra support or specialist input

  • a midwifery red flag event has occurred (see box 3).

1.3.3

Consider the following when undertaking the assessment:

  • risk factors and risk categorisation, acuity and dependency of each woman and baby in the service (use box 1 [A] as a prompt)

  • environmental factors (use box 1 [B] as a prompt)

  • time taken to perform the necessary midwifery care activities (use box 2 parts A and B as a prompt).

1.3.4

Follow escalation plans if the number of midwives available is different from the number of midwives needed (see recommendation 1.1.10). Service cancellations or closures should be the last option. Take into account the potential of cancellations or closures to limit women's choice and to affect maternity service provision and the reputation of the organisation.

1.3.5

If a midwifery red flag event occurs (see box 3 for examples), the midwife in charge of the service or shift should be notified. The midwife in charge should determine whether midwifery staffing is the cause, and the action that is needed. Action may include allocating additional midwifery staff to the service.

Record midwifery red flag events (including any locally agreed midwifery red flag events) for reviewing, even if no action was taken.

Box 3 Midwifery red flag events

A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. If a midwifery red flag event occurs, the midwife in charge of the service should be notified. The midwife in charge should determine whether midwifery staffing is the cause, and the action that is needed.

  • Delayed or cancelled time-critical activity.

  • Missed or delayed care (for example, delay of 60 minutes or more in washing and suturing).

  • Missed medication during an admission to hospital or midwifery-led unit (for example, diabetes medication).

  • Delay of more than 30 minutes in providing pain relief.

  • Delay of 30 minutes or more between presentation and triage.

  • Full clinical examination not carried out when presenting in labour.

  • Delay of 2 hours or more between admission for induction and beginning of process.

  • Delayed recognition of and action on abnormal vital signs (for example, sepsis or urine output).

  • Any occasion when 1 midwife is not able to provide continuous one-to-one care and support to a woman during established labour.

  • Other midwifery red flags may be agreed locally.

1.4 Monitoring and evaluating midwifery staffing requirements

These recommendations are for senior midwives working in maternity services

1.4.1

Monitor whether the midwifery staffing establishment adequately meets the midwifery care needs of women and babies in the service using the safe midwifery staffing indicators in box 4. Consider continuous data collection of these safe midwifery staffing indicators (using data already routinely collected locally where available) and analyse the results. The section on indicators for safe midwifery staffing gives further guidance on these indicators.

1.4.2

Compare the results of the safe midwifery staffing indicators with previous results at least every 6 months.

1.4.3

Analyse reported midwifery red flag events detailed in box 3 and any additional locally agreed midwifery red flag events and the action taken in response.

1.4.4

Analyse records of differences between the number of midwives needed and those available for each shift to inform planning of future midwifery establishments.

1.4.5

Review the adequacy of the midwifery staffing establishment (see recommendations 1.1.12 and 1.1.13) if indicated by the analysis of midwifery red flag events, midwifery staffing indicators or differences between the number of midwives needed and those available.

Box 4 Safe midwifery staffing indicators

Indicators are positive and negative events that should be reviewed when reviewing the midwifery staffing establishment, and should be agreed locally.

Outcome measures reported by women in maternity services

Data for the following indicators can be collected using the Care Quality Commission's Maternity Services Survey:

  • Adequacy of communication with the midwifery team.

  • Adequacy of meeting the mother's needs during labour and birth.

  • Adequacy of meeting the mother's needs for breastfeeding support.

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

Outcome measures

Staff-reported measures

  • Missed breaks: record the proportion of expected breaks that were unable to be taken by midwifery staff.

  • Midwife overtime work: record the proportion of midwifery staff working extra hours (both paid and unpaid).

  • Midwifery sickness: record the proportion of midwifery staff's unplanned absence.

  • Staff morale: record the proportion of midwifery staff's job satisfaction. Data can be collected using the NHS staff survey.

Midwifery staff establishment measures

Data can be collected for some of the following indicators from the NHS England and Care Quality Commission joint guidance to NHS 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.

  • Planned, required and available midwifery staff for each shift: record the total midwife hours for each shift that were planned in advance, were deemed to be required on the day of the shift, and that were actually available.

Terms used in this guideline

Acuity

Refers to the seriousness of a woman or baby's condition, the risk of clinical deterioration and their specific care needs.

Antenatal

The period of time after conception and before birth.

Contact time

The balance between time spent providing direct care and indirect care such as attendance at multidisciplinary team meetings, ward rounds and discharge planning. See the NHS England website for further details.

Dependency

The level to which a woman or baby is dependent on direct care to support their physical and psychological needs and activities of daily living, such as eating and drinking, personal care and hygiene, and mobilisation.

Endogeneity

A statistical problem that can occur when analysing data. It occurs when an outcome is partly determined by an explanatory factor. For example, when adverse outcomes are expected to be more likely to happen in a particular area of care, more qualified staff might be allocated to that area of care. This means that the techniques used in research to analyse the data can over- or under-estimate the impact of a factor (such as staffing) on an outcome (such as adverse effects).

Established labour

Established labour is when there are regular and painful contractions, and there is progressive cervical dilatation from 4 cm.

Establishment

In the context of this guideline establishment refers to the number of registered midwives funded to work in an organisation providing maternity care. This includes all midwives in post, as well as unfilled vacancies or vacancies being covered by temporary staff. Midwife establishments are usually expressed in number of whole-time equivalents.

Indicator

Positive or negative signs that can be monitored and used to inform future midwifery staff requirements or prevent negative events related to midwifery staffing levels happening in the future.

Intrapartum

The period of time from the start of labour to birth of the baby and delivery of the placenta and membranes.

Maternity care

Care and treatment provided in relation to pregnancy and delivery of a baby. It is influenced by the physical and psychosocial needs of the woman, the woman's entire family, and the baby. Maternity care is provided by a range of healthcare professionals.

Midwife/Midwifery

Qualified midwives who are registered with the Nursing and Midwifery Council.

Midwifery red flag events

Red flag events are negative events that are immediate signs that something is wrong and action is needed now to stop the situation getting worse. Action includes escalation to the senior midwife in charge of the service, and the response may include allocating additional staff to the ward or unit.

Midwifery staffing requirements

Used to describe the number of registered midwives that are needed for the establishment and on each day.

NICE endorsement programme

A new programme that formally endorses guidance support resources produced by external organisations. The programme will assess resources such as toolkits that aim to estimate nursing or midwifery staffing requirements. NICE awards an endorsement statement to toolkits that meet the endorsement criteria.

Non-registered nursing staff

Non-registered staff working in hospital or community settings under the guidance and supervision of a registered healthcare professional. Their titles may include healthcare assistant, healthcare support worker, maternity support worker, nursing auxiliary, nursing assistants and assistant practitioners. Their responsibilities vary, depending on the healthcare setting and their level of training and competence.

On-call staff

Staff who are available to work at short notice during the period of time that they are not rostered to work or off duty. The on-call arrangements should be locally agreed and should not deplete other areas of care.

One-to-one care

Care provided for the woman throughout labour exclusively by a midwife solely dedicated to her care (not necessarily the same midwife for the whole of labour).

Postnatal

The first 6 weeks after birth.

Pre-conception

In the context of this guideline, pre-conception refers to care provided by midwives to women before they are pregnant.

Preceptorship

A period of time when newly qualified midwives are supported by a clinical instructor or preceptor.

Roster

The daily staffing schedule for each maternity service.

Safe midwifery care

When reliable systems, processes and practices are in place to meet required care needs and protect people from missed care and avoidable harm.

Skill mix

The composition of the midwifery team in terms of qualification and experience.

Staffing requirement

The number and skill mix of staff needed in a service.

Supervision

Aims to safeguard and enhance the quality of care for childbearing women and their families. Its primary purpose is to protect women and babies by actively promoting safe standards through ensuring that midwives are fit to practice autonomously and by initiating action when a midwife's fitness to practice is impaired.

Temporary staff

Local bank or agency staff.

Toolkit

A practical resource to facilitate the process of calculating midwifery staffing requirements for maternity services. It may be electronic or paper-based.

Uplift

Uplift is likely to be set at an organisational level and takes account of annual leave, maternity leave, paternity leave, study leave (including time to give and receive supervision) and sickness absence.