Individual research recommendation details

Recommendation ID

NG4/1

Question

What is the relationship between midwifery staffing and outcomes in maternity settings in
England, and what factors act as modifiers or confounders of the relationship between midwifery
staffing and outcomes?

Any explanatory notes
(if applicable)

This guideline found some evidence that there is a relationship between midwifery staffing and
maternal or neonatal safety outcomes, but the evidence was weak, potentially subject to bias and
unclear about the direction of the effect. In particular, it is unclear if any of the following factors
modify or confound the relationship between midwifery staffing and maternal or neonatal safety
outcomes:
- Maternal and neonatal factors (for example, women pregnant or in labour, maternal risk factors, neonatal needs, and stage of the maternity care pathway).
- Environmental factors (for example, local geography and demography, birth settings and unit
size, and physical layout).
- Staffing factors (for example, midwifery skill mix, availability of and care provided by other
staff, division of tasks between midwives and maternity support workers, and the need to
provide additional services).
- Management factors (for example, maternity team management and administration
approaches, models of midwifery care, staff and student supervision and supernumerary
arrangements).
- Organisational factors (for example, management structures and approaches, organisational
culture, organisational policies and procedures including training).
- Cost and resource use.
Further research is needed to explore the relationships between midwifery staffing and outcomes.
This research would help to establish whether staffing ratios can be identified and recommended.
Current research is often limited by attempting to explain individual patient level outcomes as a
function of aggregate or summary level measures of midwifery staffing resource. Such techniques
may fail to adequately capture the resource input used in influencing patient-level outcomes and consequently lead to an overall biased estimate of the impact of midwifery resources on outcomes
via measurement error. Future research (preferably either cluster randomised trials or prospective
cohort studies) should attempt to obtain better measures of midwifery staff resource use
attributable to an individual. This may also require some technique to allow for the competing
demands for midwife resource on wards with several patients. In the event that observational data
is used, researchers should ideally address any issues of potential endogeneity caused by nonrandom allocation of staff, in particular where greater numbers or higher graded midwives are
allocated to address a more demanding patient case-mix.

Source guidance details

Comes from guidance

Safe midwifery staffing for maternity settings

Number

NG4

Date issued

February 2015

Other details