Is midwife workload associated with quality of process of care (continuous electronic fetal monitoring [CEFM]) and neonatal outcome indicators? A prospective study in consultant-led labour wards in Scotland

The association between midwifery staffing and reported harmful incidents: a cross-sectional analysis of routinely collected data

BACKGROUND

Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies.

METHODS

We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm.

RESULTS

The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed.

CONCLUSION

When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.

Vaginal Birth at Term - Part 1. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. This first part presents recommendations and statements about patient information and counselling, general patient care, monitoring of patients, pain management and quality control measures for vaginal birth. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG 190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in specific cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions, if this was considered necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of the additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Vaginal Birth at Term - Part 2. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. The second part of this guideline presents recommendations and statements on care during the dilation and expulsion stages as well as during the placental/postnatal stage. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in individual cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions where necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline, and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

Midwifery and nurse staffing of inpatient maternity services - A systematic scoping review of associations with outcomes and quality of care

OBJECTIVE

To undertake a scoping literature review of studies examining the quantitative association between staffing levels and outcomes for mothers, neonates, and staff. The purpose was to understand the strength of the available evidence, the direction of effects, and to highlight gaps for future research.

DATA SOURCES

Systematic searches were conducted in Medline (Ovid), Embase (Ovid), CINAHL (EBCSCO), Cochrane Library, TRIP, Web of Science and Scopus.

STUDY SELECTION AND REVIEW METHODS

To be eligible, staffing levels had to be quantified for in-patient settings, such as ante-natal, labour/delivery or post-natal care. Staff groups included midwives, nurse midwives or equivalent, and assistant staff working under the supervision of professionals. Studies of the quality of care, patient outcomes and staff outcomes were included from all countries. All quantitative designs were included, including controlled trials, time series, cross-sectional, cohort studies and case controlled studies. Data were extracted and sources of bias identified by considering the study design, measurement of exposure and outcomes, and risk adjustment. Studies were grouped by outcome noting the direction and significance of effects.

RESULTS

The search yielded a total of 3280 records and 21 studies were included in this review originating from ten countries. There were three randomised controlled trials, eleven cohort studies, one case control study and six cross sectional studies. Seventeen were multicentre studies and nine of them had over 30,000 participants. Reduced incidence of epidural use, augmentation, perineal damage at birth, postpartum haemorrhage, maternal readmission, and neonatal resuscitation were associated with increased midwifery staff. Few studies have suggested a negative impact of increasing staffing rates, although a number of studies have found no significant differences in outcomes. Impact on the mode of birth was unclear. Increasing midwifery assistants was not associated with improved patient outcomes. No studies were found on the impact of low staffing levels for the midwifery workforce.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Although there is some evidence that higher midwifery staffing is associated with improved outcomes, current research is insufficient to inform service planning. Studies mainly reported outcomes relating to labour, highlighting a gap in research evidence for the antenatal and postnatal periods. Further studies are needed to assess the costs and consequences of variations in maternity staffing, including the deployment of maternity assistants and other staff groups.

One-to-one care routines and compliance with the national professional recommendation on continuous intrapartum support in Norway: A national survey

INTRODUCTION

In 2010, the Norwegian Directorate of Health introduced the guideline 'Safe maternity services - quality standards for maternal care'. These standards include adequate staffing with health care personnel for birth units to ensure responsible monitoring and treatment. Birth units are to follow the professional recommendation that every woman has a midwife present during established labor. This study presents data from birth units on compliance with the national recommendation for one-to-one care during labor.

METHODS

A web-based questionnaire was emailed to chief midwives of all birth units in Norway (n=48) in May 2018. The questionnaire contained a total of nine multiple-choice, scaled-response-format, and free-text questions.

RESULTS

The questionnaire response rate was 100%. All birth units reported that they offered women one-to-one care during labor to a large extent. Sixty-five per cent of the birth units had procedures to ensure that midwives were present during established labor. Deviations from the recommendation were recorded in one-fourth of birth units. Thirty-eight per cent of respondents reported that staff training had been provided; 56% of birth units stated that the recommendation led to an increased presence of midwives during labor. Financial constraints (35%) and difficulty of compliance (27%) were cited as obstacles to meeting the recommendation for one-to-one care during labor.

CONCLUSIONS

The majority of birth units reported that they follow the recommendation for one-to-one care during established labor, but compliance with this recommendation in practice remains unclear. Areas of improvement relate to routines describing the presence of midwives during labor, registration of deviations, and staff training in one-to-one care.

The Association Between Hospital Capacity Strain and Inpatient Outcomes in Highly Developed Countries: A Systematic Review

BACKGROUND

Increases in patient needs can strain hospital resources, which may worsen care quality and outcomes. This systematic literature review sought to understand whether hospital capacity strain is associated with worse health outcomes for hospitalized patients and to evaluate benefits and harms of health system interventions to improve care quality during times of hospital capacity strain.

METHODS

Parallel searches were conducted in MEDLINE, CINAHL, the Cochrane Library, and reference lists from 1999-2015. Two reviewers assessed study eligibility. We included English-language studies describing the association between capacity strain (high census, acuity, turnover, or an indirect measure of strain such as delayed admission) and health outcomes or intermediate outcomes for children and adults hospitalized in highly developed countries. We also included studies of health system interventions to improve care during times of capacity strain. Two reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Score for observational studies and the Cochrane Collaboration Risk of Bias Assessment Tool for experimental studies.

RESULTS

Of 5,702 potentially relevant studies, we included 44 observational and 8 experimental studies. There was marked heterogeneity in the metrics used to define capacity strain, hospital settings, and overall study quality. Mortality increased during times of capacity strain in 18 of 30 studies and in 9 of 12 studies in intensive care unit settings. No experimental studies were randomized, and none demonstrated an improvement in health outcomes after implementing the intervention. The pediatric literature is very limited; only six observational studies included children. There was insufficient study homogeneity to perform meta-analyses.

DISCUSSION

In highly developed countries, hospital capacity strain is associated with increased mortality and worsened health outcomes. Evidence-based solutions to improve outcomes during times of capacity strain are needed.

The association between attendance of midwives and workload of midwives with the mode of birth: secondary analyses in the German healthcare system

Background

The continuous rise in caesarean rates across most European countries raises multiple concerns. One factor in this development might be the type of care women receive during childbirth. ‘Supportive care during labour’ by midwives could be an important factor for reducing fear, tension and pain and decreasing caesarean rates. The presence and availability of midwives to support a woman in line with her needs are central aspects for ‘supportive care during labour’.

To date, there is no existing research on the influence of effective ‘supportive care’ by German midwives on the mode of birth. This study examines the association between the attendance and workload of midwives with the mode of birth outcomes in a population of low-risk women in a German multicentre sample.

Methods

The data are based on a prospective controlled multicentre trial (n = 1,238) in which the intervention ‘midwife-led care’ was introduced. Four German hospitals participated between 2007 and 2009.

Secondary analyses included a convenience sample of 999 low-risk women from the primary analyses who met the selection criterion ‘low-risk status’. Participation was voluntary. The association between the mode of birth and the key variables ‘attendance of midwives’ and ‘workload of midwives’ was assessed using backward logistic regression models.

Results

The overall rate of spontaneous delivery was 80.7% (n = 763). The ‘attendance of midwives’ and the ‘workload of midwives’ did not exhibit a significant association with the mode of birth. However, women who were not satisfied with the presence of midwives (OR: 2.45, 95% CI 1.54-3.95) or who did not receive supportive procedures by midwives (OR: 3.01, 95% CI 1.50-6.05) were significantly more likely to experience operative delivery or a caesarean. Further explanatory variables include the type of hospital, participation in childbirth preparation class, length of stay from admission to birth, oxytocin usage and parity.

Conclusion

Satisfaction with the presence of and supportive procedures by midwives are associated with the mode of birth. The presence and behaviour of midwives should suit the woman’s expectations and fulfil her needs. For reasons of causality, we would recommend experimental or quasi-experimental research that would exceed the explorative character of this study.

Every woman needs a midwife, and some women need a doctor too

Global recognition is increasing of the contribution of midwifery services to optimal outcomes for women and babies, and evidence around how to organize services and the roles of maternity providers. However, a sociological analysis can provide some insight into why the role of midwives varies so widely in different countries. Evidence is necessary, but more important is the role of the state in legalizing and financially supporting midwifery practice, how professional boundaries are negotiated in the maternity care domain, and consumer mobilization in support of midwifery and around maternity issues.