Providing one-to-one care in labour. Analysis of ‘Birthrate Plus’ labour ward staffing in real and simulated labour ward environments


M Allen, PenCLAHRC (Peninsula Collaboration for Leadership in Applied Health Research & Care), University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK. Email


Please cite this paper as: Allen M, Thornton S. Providing one-to-one care in labour. Analysis of ‘BirthratePlus’ labour ward staffing in real and simulated labour ward environments. BJOG 2012; DOI: 10.1111/j.1471-0528.2012.03483.x.

Objective  To assess the ability of the ‘Birthrate Plus’ (BR+) midwife staffing system to cope with variability of workload on labour wards.

Design  Retrospective analysis of labour ward workload and computer simulation of labour wards.

Setting  The labour ward of a city hospital.

Population  A total of 5800 births (1 year).

Methods  The variation in births by time and day was analysed over a 1-year period. Three months of BR+ data were analysed for variation of workload by case mix. A computer simulation model was built to allow prediction of the impact of changing resource levels or shift patterns, and to forecast the impact of changing number of births per year.

Main outcome measures  Labour ward overloading (when either the number of women or the BR+ Workload Index exceeds the scheduled midwife availability).

Results  Labour ward overload occurred 37% of the time when applying the BR+ method. Underlying patterns of workload were present and simulation indicated that overload could be reduced by 15–25% if available resources were matched more closely to known patterns of workload. Simulation also indicated that smaller units are predicted to suffer from overload more often than larger units, and are more prone to severe overload.

Conclusions  The BR+ formula for midwife staffing leaves labour wards vulnerable to significant periods of overload. Matching resource levels to known patterns of workload may reduce the occurrence of overload. Simulation indicates that smaller units need higher relative staffing levels to provide the same level of 1:1 care to mothers in labour.