A study of the relationship between midwife staffing levels and patient experience
A growing body of research has linked staffing levels on maternity wards to patient outcomes and experiences of care. To build on this area of study, a cross-sectional analysis linked women’s responses to a maternity survey to midwifery staffing levels in different trusts. Its findings suggested a positive relationship between staffing and patient experience, although more research is needed to clarify this and explore longer-term outcomes.
Citation: Turner L et al (2022) Are poor experiences on postnatal wards linked to staffing levels? Nursing Times [online]; 118: 12.
Authors: Lesley Turner is senior teaching fellow in midwifery; David Culliford is principal research fellow; Jane Ball is professor of nursing workforce policy; Ellen Kitson-Reynolds is principal teaching fellow in midwifery; Peter Griffiths is chair of health services research; Christina Saville (editor) is research fellow; all at University of Southampton.
The United Nations Population Fund’s (2021) report The State of the World’s Midwifery 2021 identified that postnatal care is not appropriately prioritised, leading to unmet need in many countries. Midwives’ potential impact on mortality prevention is substantial (Nove et al, 2021), and higher staffing levels have been associated with fewer adverse events, neonatal unit admissions and maternal readmissions (Turner et al, 2021).
More needs to be done to establish good maternal and infant health in the early days after birth (Malouf et al, 2019); over half of all women who give birth in hospital or a birth centre in the UK are discharged within 24 hours. Some report negative experiences, such as staff being too busy to give practical help or assist post-operative mothers (Harrison et al, 2021).
A scoping literature review of women’s experiences of hospital postnatal care by Turner et al (2021) summarises the growing body of research in midwifery that links staffing levels to outcomes and patient experiences; this article highlights new research that builds on this.
The researchers undertook a cross-sectional secondary analysis that linked responses from a 2018 maternity survey to staffing data for midwives; the UK Data Service provided anonymised individual patient data after the study gained ethical permission – this was published by the Care Quality Commission and Picker Institute Europe (2020). In total, 129 trusts and 17,611 respondents were included. The survey’s response rate varied from 21-61% between trusts, with an overall response rate of 37%. The number of full-time-equivalent (FTE) midwives was extracted from NHS Digital’s (2018) workforce statistics, which matched the time period for women giving birth in the maternity survey.
Four closed questions asked specifically about the woman’s experience of postnatal care:
- Did they experience a delay in discharge?
- Did they receive help from staff within a reasonable time?
- Were they given the information or explanations they needed?
- Were they treated with kindness and understanding?
A regression model was fitted for each of the four questions to investigate the effect of staffing on the chance of respondents answering:
- “Yes, always”;
- “Yes, sometimes” or “No”.
This was multilevel to account for different trusts, and logistic because two possible answers were being considered. Because parity, type of birth, age, ethnicity and size of trust may also affect women’s experiences, the researchers controlled for these in their models. They analysed staffing as a continuous variable, then explored potential non-linear relationships by dividing the variable into tertiles (three groups of trusts with similar staffing levels).
The median number of FTE midwives per 100 births was 3.55; the middle half of hospitals had 3.26-3.78. This represents the number of midwives in organisations, because it was not possible to determine the number deployed on postnatal wards themselves.
There was some variation in women’s responses to the questions about their experiences, based on their age group, parity and type of birth. For example, women in the youngest age group, first-time mothers and those having instrumental or Caesarean-section births reported more negative experiences.
Women cared for in trusts with higher levels of midwifery staffing had more favourable responses to each of the questions on postnatal care. The researchers estimated that every additional FTE midwife per 100 births in the organisation is associated with:
- 15% reduction of delays in discharge: adjusted odds ratio (OR) 0.85, 95% confidence interval (CI) 0.75-0.96;
- 20% increase in staff always helping in a reasonable time: adjusted OR 1.20, 95% CI 1.05-1.37;
- 15% increase in women receiving the information and explanations they needed: adjusted OR 1.15, 95% CI 1.04-1.27;
- The relationship for being treated with kindness and understanding being in the same direction but not statistically significant: adjusted OR 1.06, 95% CI 0.95-1.18).
The absolute difference in the number of women answering negatively was calculated between hospitals with low, medium and high staffing levels (grouped in tertiles). The largest difference was seen in the survey question about discharge: an estimated 5.7% fewer women (1 in 18) reported a delay in discharge in trusts in the highest tertile for staffing (3.7-5.2 FTE midwives per 100 births) compared with the lowest tertile (2.5-3.4 FTE midwives per 100 births). Estimates for the middle tertile fell between the lowest and highest, which suggests a roughly linear relationship between staffing and patient experience.
The information provided by the study’s data analysis can be used alongside safety measures to inform staffing decisions.
The study found improved maternal experiences in trusts employing a higher number of midwives. The effect sizes are relatively small, although they could amount to a sizable difference given the number of women receiving maternity care each year. For example, for a maternity unit with 5,000 births per year with high staffing (≥3.7 FTE midwives per 100 births), 285 fewer women may report a delay in discharge and 205 may report being helped in a reasonable time compared with a smaller unit with low staffing (<3.5 FTE midwives per 100 births).
Although the findings suggest more staffing is related to positive effects, a causal link cannot be attributed, because results come from a cross-sectional study. The staffing levels in this study were not measured at ward level, therefore, differences seen at organisational level may not translate into proportional staffing on postnatal wards. Further research could explore this with greater accuracy and include support worker staffing in the workforce variables.
Maternity staff are becoming more aware of the impact of their services on women’s experiences, for example through the development and implementation of NHS England’s (2018) Fifteen Steps for Maternity challenge. Although previous studies have found that maternity staffing is linked to outcomes, such as maternal readmissions and breastfeeding (Turner et al, 2021), the impact on patient experience is also important.
One in five women experience mental health problems during pregnancy or in the first year after birth (Royal College of Obstetricians and Gynaecologists, 2017); it is, therefore, important to ensure their postnatal experience does not add to these difficulties.
This is the first study to examine the effects of organisational staffing on women’s experiences of hospital postnatal care. There is some evidence that higher midwifery staffing is associated with better experience of care on postnatal wards. Further research is needed to clarify this relationship and establish links between the quality of postnatal care and longer-term outcomes for mothers and babies.
- A study analysed national maternity survey results against NHS staffing data
- The study found improved maternal postnatal experiences in trusts employing more midwives
- Higher staffing levels were linked to patients reporting better information and more timely support
- When more midwives were employed, fewer women reported a delayed discharge
- More research is needed, including on longer-term outcomes and the contribution of support workers
- This article is reproduced from: Turner L et al (2022) Are poor experiences on postnatal wards linked to staffing levels? Evidence Brief; 1-2: 21. eprints.soton.ac.uk/455725. Reproduced under the terms of a creative commons attribution CC-BY (4.0) license.
This research was partly funded by the National Institute for Health Research (NIHR) Health Services & Delivery Research programme (award ID: NIHR128056) and the NIHR Applied Research Collaboration (Wessex). The views expressed are those of the authors and not necessarily those of NIHR, Department of Health and Social Care, arm’s-length bodies or other government departments.
Care Quality Commission, Picker Institute Europe (2020). Maternity Survey, 2018. [data collection]. UK Data Service. SN: 8596.
Harrison S et al (2021) You and Your Baby: A National Survey of Health and Care during the 2020 Covid-19 Pandemic. Policy Research Unit in Maternal and Neonatal Health & Care (PRU-MNHC), National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford.
Malouf R et al (2019) Expectations and experiences of hospital postnatal care in the UK: a systematic review of quantitative and qualitative studies. BMJ Open; 9: e022212.
NHS Digital (2018) NHS Workforce Statistics – February 2018. NHS.
NHS England (2018) The Fifteen Steps for Maternity: Quality from the Perspective of People Who Use Maternity Services. NHS England.
Nove A et al (2021) Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. The Lancet Global Health; 9: 1, e24-e32.
Royal College of Obstetricians and Gynaecologists (2017) Maternal Mental Health: Women’s Voices. RCOG.
Turner L et al (2022) The association between midwifery staffing levels and the experiences of mothers on postnatal wards: cross sectional analysis of routine data. Women and Birth; S1871-5192: 22, 00031-2.
Turner L et al (2021) Midwifery and nurse staffing of inpatient maternity services: a systematic scoping review of associations with outcomes and quality of care. Midwifery; 103: 103118.
United Nations Population Fund (2021) The State of The World’s Midwifery 2021. UNFPA.
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