Staffing and quality of care of inpatient maternity services

Abstract

Maternity services are reported to be under resourced and there is a national shortage of midwives. There is little empirical evidence on the relationship between staffing levels and the quality of care, so the consequences of understaffing are unclear. This thesis comprises four studies that aim to explore the association between variation in midwifery staffing levels and a range of outcomes to better understand the likely consequences of understaffing.

Secondary data from published and unpublished sources have been used. Study designs include three cross-sectional and one longitudinal study. Multiple regression techniques were used to separate staffing effects from those associated with individual characteristics, care interventions and service differences. Staffing and outcomes were measured as close to women as possible to understand relationships in greater depth.

The first study used staffing and survey data from 129 NHS trusts and found an association between more full-time equivalent midwives and women reporting a better experience of postnatal inpatient care. Fewer women reported delays in discharge in organisations with higher
midwifery staff, and more women reported that staff always helped in a reasonable time, and they always had the information and explanations they needed. The second study continued to investigate postnatal care experience but delved more deeply using staffing data from 123
postnatal wards within 93 NHS trusts, including both midwives and support workers. Wards with higher support worker staffing were associated with higher rates of women reporting they always had help when they needed it and were always treated with kindness and understanding.
The next two studies accessed individual patient data from three NHS trusts over forty-six months covering 106,904 maternal admissions, of which 64,250 admissions resulted in a birth.

Variation was noted in midwifery staffing and the demand for care. Understaffing by midwives was significantly associated with higher rates of postnatal readmissions and more reported harmful incidents. These findings were not replicated for understaffing by maternity support
workers. Days with higher than expected admissions and discharges were associated with higher rates of harmful incidents. The relationships have not been confirmed as being causal, as evidence comes from observational studies.

The evidence presented in these four research studies highlights the potential impact of understaffing on a range of outcomes, not just those relating to labour care. This work justifies the need to combat low staffing levels and match staffing to needs in all inpatient settings.
Maternity support workers contribute to women’s experience of care but should not be deployed as a substitute for midwives. Further work is needed to strengthen the evidence base on multi-professional staffing and to understand the impact of setting staffing standards to
guard against critical understaffing of maternity services.

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Identifiers

ORCID for Lesley Turner: orcid.org/0000-0003-1489-3471

ORCID for Peter Griffiths: orcid.org/0000-0003-2439-2857

ORCID for Ellen Kitson-Reynolds: orcid.org/0000-0002-8099-883X

ORCID for Jane Ball: orcid.org/0000-0002-8655-2994

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