Midwife shortage? Hello? 28 births per midwife per year?

[Ushy]

I don't want to midwife bash because I know how hard some work but I couldn't believe it when I read that midwives are complaining that they are overworked and they want to reduce their workload to 28 babies PER YEAR from around 32 or 33!!! PER YEAR? I thought I must have misheard and they meant a month but no, a year. How come then, there is not already enough midwives for every woman to have good quality one to one care in labour and postnatally without us tax payers having to pay for more? Can someone explain?

[working9while5]

Midwives here, would you mind telling me in the context of this discussion how do you feel about people like doulas/independent midwives etc? (Know they are NOT the same). I never, ever want to repeat my postnatal experience, it was the darkest night of my whole life, so I am considering independent midwifery.. NOT because I felt that there was anything wrong with the people who delivered my NHS care who were all very personable etc but just because I would like to have someone who has the time to go through what happens and debrief me etc and this didn't happen last time.

I had a deep transverse arrest following induction at 40+13 after SROM at 40+11, large baby (9lbs) delievered by Kielland's forceps, ds had Apgar of 6, didn't cry for a minute etc and while I was very calm during my labour last time (because I had no idea really how unpredictable birth can be!) I am really concerned about having my next baby and would like the assurance that I will have 1 to 1 care to help me labour. Do NHS midwives think it is terrible to have an independent midwife on the scene? I just don't want to be alone not knowing what's happening because of staff shortages etc and if that's the only way to protect myself, I feel I have to do it.. but worry that it would set staff against me if I ended up in hospital?

[mintpurple]

I've no idea what you're meaning by midwife days etc, but you would have to be a bit naive to believe any statistics without delving a bit deeper.

Midwives who deliver babies are only a very small part of the greater picture. The majority of midwives actually work in antenatal, postnatal, community, antenatal clinics, specialist midwife roles, 1-1 caseloading, management, fetal medicine - the list is long and few of these midwives will deliver babies, but provide all the other care and input necessary to ensure that you receive an appropriate package of care.

When I worked in Labour ward I would deliver about 200 babies a year, and probably care for 4-5 times that many women in various stages of labour or antenatally. When I worked on Caseload which involved homebirths and caring for vulnerable women, I had about 35 women a year to provide complete care for (to the extent that, aside from scans, they may never have contact with anyone from the hospital but me, from the start to the end of pregnancy). So if you take the midwives who don't deliver babies and add them into the equation, then 28 is probably fairly realistic PER EMPLOYED MIDWIFE. If you took the midwives away from any of the areas where they provide care but don't deliver babies, there would be a mass of threads on here complaining about a lack of care in some other department.

When we work 3 days a week, that usually means 12-14 hour shifts, often without breaks, maybe a coffee or sandwich gulped down between patients or while writing in notes if we're lucky. And the paperwork involved is just ridiculous - we can spend almost as long doing notes and computer work for each patient as we do actually caring for them one to one.

So before launching into another tiresome and antagonistic 'OMG - midwives only deliver 30 babies a year and why are we paying taxes for this' thread, give a bit of credit to the fact that in general, midwives actually do a pretty good job under the restraints imposed by recent government economic policy in regard to the NHS.

I too am getting a bit fed up with the recent threads in which midwives are seen as the enemy.

[breatheslowly]

I think that there is a lot of hostility towards Ushy on this thread.

From the POV of a low risk pregnancy and higher risk birth I would list the time I spent with a MW as follows:

AN care - Booking in appointment 1 hr, 6x 15 min standard appointments, 2x 30min sweep appointments - Total 3.5 hours. Presumably there was admin along side this. I assume scan appointments are sonographer time, not MW.

Hospital care - Talking me into having an induction - 1 hour. 3 days of induction with pessaries/gel x 4. Approx 1.5 hours each (alternatively you could look at this from the POV of having approx 10 women and 24 hour cover for 3 days, so 7.2 hours instead of 6). This included time setting up the foetal monitoring for before and after. Labour 9 hours (on the short side) - 1:1 care thoughout due to induction. Care on the labour ward overnight due to shock and transfusion 2 hours. 18 hours

PN ward - 2 days as one of about 20 women with 1 MW at any time and 24 hour cover - say 3 hours. It is really hard to believe that my experience of the PN ward reflected 3 hours of care as it was a hellish place with insufficient staffing. Total 3 hours

PN community - 2 visits - say 1.5 hours each to include travel time. A couple of phone calls - say 0.5 hours. Total 3.5 hours

Hospital care for broken down episiotomy. 1 hour

Debrief - 2 hours

So I am coming out at 31 hours. Assuming 7.5 hour working days This is about 4 days work.

I am sure that some of my estimates are wrong and I haven't included enough admin time.

So if an area has an FTE staffing of 1 to 28 births then they would have an average cover of 8 MW days per woman. As an individual service user it is difficult to see where "the other 4 days of MW time went". As a MW is only 50% of your time spent with patients or was I a "heavy service user"? Admittedly few areas have this idea level of staffing so the question is probably more "where did the other 2 days go?"

I think it is a fair question - how do MW spend their time and is it an appropriate use of their time? Could any of their role be performed by someone else as it takes a long time to train up MW and maternity services are overstretched now.

[mintpurple]

wow - this threads moved on since I started that last post! :)

[Ushy]

iteotwawki I agree with you that the scope of a midwives job is very wide but the really important aspects are the initial antenatal check, the time during birth and the immediate period afterwards. That is where the focus needs to be. Midwifery management needs to make sure all the non-midwifery jobs are dumped so midwives can focus on core functions not menial jobs that can be done by unskilled people.

What I am getting at is that the way the economy is at the moment the chance of getting extra midwives is pretty remote. That means that things stay as they are. That isn't good enough is it? Not if there are at least some things that could be done to make things better with the current money that is available.
Sorry working9while5 hope someone answers your question and good luck!

[Quidsi]

Ushy I agree that if everything is going smoothly (as per my 1st and 3rd pregnancy) then I didn't need to see my MW much.
But what about when we were given bad news (potentially life threatening news) at our scan and told to come back in a week. Who do you think was there for us then? My MW.
I think I know what you are trying to say but tbh I think you are saying it badly. I think you are saying that there are tasks that the MWs do that could/should be undertaken by others in order to free up the MWs time.
I just don't think its that simple.

[mintpurple]

working9while5 - you would be welcome to bring in an indie mw or doula as you wish, would make no difference as to how I would care for you at all, but if it would make you feel better to have someone then it would be money well spent. I would be inclined to go with the doula rather than the indie as they will be much cheaper (:)) and the indie mw will only be able to act as a doula anyway unless you decide on a homebirth.

Personally I really like having doulas in during a labour, often we learn from each other and have interesting discussions (as appropriate of course), and Ive met some fantastic doulas in my time as a mw.

[mintpurple]

no its not that simple at all. There is no-one else to make the tea and find the pillows and mop the floor and change the bed, dress the baby, restock the room, do the paperwork etc. And if we were going to hire several more HCA's (health care assistants) each shift then it would make more sense to hire another midwife. But there is no more money in the pot.

There are lots of midwives looking for jobs but the hospitals are not hiring. In a recent round of adverts for jobs in our hospital, we had 10 midwife applicants for each job, so its purely economics which keep staffing levels short.

And Ushy - personally I think we could talk till were blue in the face about this but I still don't think you will actually get it. Would like to be able to take you to work with me one day and I think you'd change your ideas then.

[mathanxiety]

'Could any of their role be performed by someone else as it takes a long time to train up MW and maternity services are overstretched now.'

In the US the nursing end of things is done by nurses who are not midwives. The medical/surgical aspect of maternity service is provided by OB/GYNs, hospital residents and certified nurse midwives [CNMs] (but not surgical in the case of midwives iirc).

Nurses (RNs) do four year or equivalent college degrees in nursing. OB/GYNs do much more, obv. The residents are doing their OB/GYN training. Certified Nurse Midwives receive extra education on top of the basic RN training. There are other midwifery qualifications and paths into the career but licensing to practice is dodgy without the CNM qualification.

You go to an OB/GYN or midwife practice that has admitting privileges at a local hospital for your antenatal care and have your monthly visits at their office, then bi-weekly visits, then weekly around 40 weeks, then as needed after that. You go to the hospital when you go into labour and are examined by nurses in the triage area, then admitted if you are in labour and moved to a room for L&D, or sent home if not. You would have called your doctor or midwife and they might or might not get there asap. Meantime, a hospital resident would check you after nurses took vital signs, hooked you up to an IV, and performed any other routine procedures the hospital deemed necessary. You would be accompanied by a nurse during labour.

In the hospitals I delivered in, the same nurse would be taking care of you for her entire shift. In the case of induction, you are supposed to have a nurse with you at all times. With a midwife, you would have your midwife there for as much of the L&D as she could manage but definitely a nurse too. The doctor or MW would visit periodically throughout labour to check, perform internal exams and would attend the delivery, again supported by a nurse. You might have the hospital resident on duty or you might have your own doctor or midwife. Postnatal care was all delivered by L&D nurses.

[breatheslowly]

So the US model wouldn't be any use and the issue isn't the number of trained midwives either. It's just underfunded which is very sad, but so are lots of other areas of the NHS. I feel a bit defeated by this discussion. You can see why the question was asked as anyone with a straightforward pregnancy and birth sees only the tip of the iceberg when it comes to MW time.

[VivaLeBeaver]

Our hospital has now delegated some of the "low risk" post natal visits to health care assistants. So it is an unqualified assistant who will go and do the home visit, help with breast feeding, ask the woman if she's ok, etc. Now I assume they have some training but nowhere near the three years it takes to become a midwife.

So what happens when the woman tells the hca that's she's feeling a bit fluey and the hca thinks nothing of it. But twomdays later she drops dead from a raging strep a infection. What happens when the hca doesn't recognise jaundice and days later baby is rushed into hospital very poorly and potentially doesn't recover.

You guessed it, the local community midwife will be hung, drawn and quartered. Suspended and possibly struck off because the buck stops with her even if she wasn't there. Anyone apart from a midwife who does anything, it is deemed that the midwife has delegated the work. If you delegate work then the work that is done is done under your pin number and your registration.

I had to leave a fairly junior student who I'd never worked with before to look after a labouring lady on her own the other week. I was pooing my pants as I knew that if something went wrong it would be me in the shit.

[fruitybread]

I don't want to hijack the thread, but just want to ask, quickly -

viva (and any other MWs on the thread who have faced similar dilemmas) - when you do something in the course of your work that you feel puts a patient in danger - like viva leaving a junior student whose competency she was clearly worried about in charge of a woman, or delegating work to people you feel are not competent -

Is this something you can raise in your workplace? Do you do this, and to whom, and what is the reaction? It just strikes me that if most MWs are saying on record, on a regular basis, 'during the course of my work, I had no choice but to leave patient x with an underqualified/untrained person who I feel did not have professional competency to handle the situation, and feared this would endanger the patient' - then a large number of internal complaints would be ringing alarm bells somewhere, if only from a potential litigation POV.

And viva, could you explain a bit more about how unqualified healthcare assistants are given patients to visit postnatally? I can't tell from your post if it is the MW who 'delegates', i.e decides who they visit, or if someone else does, sorry.

[Haribojoe]

You can escalate concerns about safety and clinical situations through clinical risk reports.
These are reviewed by management and then at trust level. They can help bring about change but it's a long process and takes a lot of reports about the same thing before things may change.

I'm proud of my profession and feel privileged to be caring for women at such a special time. But the misconceptions about what we do and how we do it make me so sad.

[kat2504]

It can't be that difficult to understand can it?
I have recently been cared for by midwives on the Early Pregnancy Assessment Unit. By the very nature of their job, they will have zero births per midwife per year.
The midwife I see in my GP surgery probably does not attend many births per year as he runs an antenatal clinic.
The midwives on the delivery suite will have a heck of a lot more births per year than the others.

It's all about averages. Just because a midwife is not delivering babies does not mean his/her time is not being well managed by the NHS

[GetThePartyStarted]

I think that there is a lot of red tape and inefficiencies that stop midwives (most of which are lovely, very hard working and busy) from doing their jobs to the best of their abilities.

For example, my lovely lovely community midwife was only allowed to run one clinic a week at our GPs, which was always overbooked. All the women who could not get one of the extra "emergency overflow" appointments (which were almost always all taken up in advance as there were not enough normal appointments available so no room for actual emergencies) had to be seen at home in the rest of the week. So instead of seeing 18 women in 3 hours at the clinic one after another she would have to spend say 9 hours seeing them as she had to travel to see each of them individually.

She was so frustrated but was still so kind and lovely. But what a waste of her time!!!!! That is where a lot of the time disappears to I would bet.

[Ushy]

Getthepartystarted I totally agree and that is what I am getting at. Isn't the scenario you describe a perfect example of where the midwives load and stress could easily have been reduced.

I am not blaming midwives at all because the overwhelming majority do a brilliant job BUT it seems the NHS is not the most efficient of organisations and doesn't let the people working at the sharp control what happens enough, make improvements and make the whole thing more efficient.

It isn't acceptable that so many women get really poor care around the birth but particularly postnatally. It is equally unacceptable that midwives are doing 12 hour shifts without proper breaks and feeling stressed and rushed off their feet.

So do we just wait for the government in the middle of the biggest downturn for 70 years to shell out however many hundred million for the 4 or 5000 extra midwives? I think it is worth a try but I wouldn't hold my breath.

So the only alternative is to look at HOW the service works, just like Getthepartystarted said, give midwives more say in controlling how things work so they work more effectively and dump some jobs just can't or don't need to be done.

[fraktious]

I found the breakdown of time interesting. I'm not in the UK and I had in actual contact hours:

6 x 30mins appts
2 hrs with a specialist midwife
30 mins personal tour of the maternity section
6 x 2hrs antenatal classes
1hr visit for suspected leaking waters
6hrs chest pain and that would have been an overnight stay if I'd consented
1 x 1hr appt at 40 weeks
30 mins assessment in early labour
4? X 5 min checks
30 mins in active labour/transition
30 mins pushing
2 hours postnatally being stitched, DS checked
30 mins on the postnatal ward that night
5 x 10 min obs (3 mornings, 2 evenings)
1 hr with a specialist BF MW
10 mins talk on contraception
1 hr DS checked for discharge and heel prick on day 3

(3 days in hospital then discharged from MW care)

I wouldn't class myself as a particularly heavy service user, I had a physically uncomplicated pregnancy and really wanted to be left alone as much as possible.

I probably had another 5 hours with an ob/gyn for scans, booking in, postnatal checkup and 1 hour arguing with an anaesthetist.

I had fantastic continuity of care - 1 MW antenatally, 1 MW for classes, 1 MW for labour/delivery and the same 2 MWs (mostly 1 though) postnatally.

Where I am it seems staffing levels are high and it shows. The majority of what I needed had to be done by a MW and the continuity was a huge bonus. I can see where the time would go even on an uncomplicated case like mine.

[Ushy]

Fraktious that's really interesting - can I ask if where you are is a socially funded health service like the NHS or is it an insured system? Also, were the 12 hours of antenatal classes individual - I assume not but I was trying to calculate how much one to one care you actually got.
Thanks!

[tittybangbang]

"could you explain a bit more about how unqualified healthcare assistants are given patients to visit postnatally? "

In my area maternity support workers with NO qualifications in breastfeeding support and no formal training in recognising possible postnatal problems in women or babies were being sent out unsupervised to do the day five visit and heel prick test. As far as doing to heel prick test - it was see one, try one, do one. And then do one unsupervised.

[fraktious]

Maternity care is funded at 100% things like a private room are paid by top up health insurance.

Antenatal classes there were 6 of us, dropped to 5 as 1 had her baby early. I had the option of individual prep, as does everyone in my area, which would have been 3 1 hour sessions IIRC? But that might have been partially funded, partly paid by insurance. I wanted to meet other people though!

I get the feeling I could have had more care if I'd wanted IYSWIM. I didn't get the impression that they were stretched or harassed, but when I worked with PN mothers in the UK I definitely got that vibe from the MWs I saw and the mothers said the same. No matter how good they are and how caring and attentive they currently have too much work and I do think that negatively impacts on care.

[VivaLeBeaver]

I'm not sure who delegates the work tomthe hcas as I don't work in community. I know they have no qualifications and I know they do visits on their own. Whether individual midwives tell them can you say x and y or whether there is some other system I don't know.

I do fill out risk management forms where I think there s been a near miss and this is done frequently. I filled out four so far this month, they all take about an hour to do. So that's more time wasted. We fill out so many forms about staffing levels to patient ratio that we've been told to stop doing individual forms but to fill out one a month with a list of affected dates/shifts.

[breatheslowly]

That's classic Viva - filling out a form that takes an hour where if you had a free hour at the right time you probably wouldn't have needed to fill out a form.

[mathanxiety]

'For example, my lovely lovely community midwife was only allowed to run one clinic a week at our GPs, which was always overbooked. All the women who could not get one of the extra "emergency overflow" appointments (which were almost always all taken up in advance as there were not enough normal appointments available so no room for actual emergencies) had to be seen at home in the rest of the week. So instead of seeing 18 women in 3 hours at the clinic one after another she would have to spend say 9 hours seeing them as she had to travel to see each of them individually.'

What does this say about the quality of management?
And the length of time to fill out a form? Ludicrous.

In my experience the US system worked well, with nurses doing the more mundane monitoring and post natal care and MWs or doctors there for the delivery and occasional checking of progress. I personally experienced only one delivery (out of five) where the hospital was really busy and my nurse wasn't there with me for about half an hour as she was called to assist in another room. It shouldn't have happened though as I was being induced. There wasn't enough time for the anesthetist to give me an epidural that time either [grrrr].

However, in the US, nobody visits you after the birth at home. You are completely on your own once you leave the hospital. You bring your baby for a checkup at two weeks and you go for your own post natal checkup at six weeks.

[Ushy]

mathanxiety I agree with your comment about it being ludicrous ..and as for taking an hour to fill a form to report an incident that almost certainly arose because of lack of time..

BUT Viva Haribojoe Mintpurple and all the other midwives on this thread - suppose we said YOU design the service you deliver. I worked out you have 50 hours individual time for each woman with CURRENT staffing. Your constraints would be: one to one care in labour, high quality postnatal care, a good booking appointment, good records, other care as indicated by NICE guidance. You could shift ward 'stuff' round so that it was easily accessible and reorganise the physical environment as much as you like and you could delegate to HCAs as you wish - providing you also engage with them to get their views. Unnecessary jobs you could dump.

I bet you would come back with a blue print to develop one of the best maternity services in the world and there would not be a single mindnumbing senseless bit of paperwork in the building, no-one would be stressed and running round like headless chickens AND you wouldn't have cost tax payers a penny!

[Ushy]

Must add one thing - not only would it be better but I reckon it would be safer!