Childbearing women should receive a personalised service that meets their needs. For this to occur, we need to embrace the assistance of well trained support workers
Maureen Brown, MA, BSc, RM, RN, is associate head of nursing, midwifery and healthcare; Susan Lees, MSc, BSc, RM, RN, and Susan Law, MSc, BSc, RM, RN, are senior lecturers; Natalie Mills, MSc, BSc, RN, is head of continuing professional development; all at Coventry University; Carmel McCalmont, MA, BSc, PGCert, RM, RN is divisional nurse and head of midwifery, University Hospitals Coventry and Warwickshire NHS Trust.
Brown M et al (2010) Are maternity support workers the key to facilitating choice in childbirth? Nursing Times; 106: 43, early online publication.
Maternity services need to meet the demands of an increasingly diverse and rapidly growing population. Recent policy changes mean midwives are taking on roles formerly performed by doctors, leaving maternity support workers (MSWs) to undertake many traditional midwifery tasks. This article discusses the development of the MSW role, and how they can facilitate choice by helping midwives deliver a flexible, personalised service to childbearing women.
Keywords Maternity support workers, midwife, choice, childbirth
- This article has been double-blind peer reviewed
- Maternity support workers (MSWs) can help free up midwives’ time by taking on roles such as clerical work, breastfeeding support and parent education. This allows midwives to spend more time with women in labour on a one-to-one basis
- MSWs can be trained to act as a second person at a home or hospital birth, to take over the scrub role in obstetric theatres, and carry out neonatal blood tests and abdominal examinations
- To deliver the Maternity Matters agenda (Department of Health, 2007), midwives need to view the MSW role as an enhancement to the care they provide for childbearing women.
The implementation of the European Working Time Directive (EWTD) in August 2009, limits the number of hours junior doctors can work (Department of Health, 2009). Midwives are therefore taking on extended roles, such as intravenous cannulation and full newborn examination, leaving maternity support workers to undertake some of the more traditional midwifery tasks
Maternity Matters (DH, 2007) emphasised the need for flexible, personalised maternity services. The report made of number of ‘national choice guarantees’ for childbearing women, including choice of type of antenatal care, postnatal care and place of birth
Major changes taking place in healthcare offer an ideal opportunity to change women’s experiences of childbirth for the better. Healthcare workers are taking on new roles, and services are being commissioned and funded in new ways. Maternity services need to meet the needs of an increasingly diverse population and practitioners who care for childbearing women must be highly skilled to facilitate choice and provide a positive experience of child birth. All healthcare professionals need to understand the meaning of informed choice and be able to facilitate it (NICE, 2008).
The role of the maternity support worker (MSW) may be key to delivering choice in childbirth, and hugely important in making choice a reality. The potential impact of the MSW role on childbirth choices could be direct - through the provision of additional skills and supporting the midwifery workforce - or indirect through the adoption of activities that free up the time of midwives.
One of the most effective ways to facilitate choice in childbirth is by educating childbearing women and empowering them to make informed choices. Midwives may be responsible for providing the evidence based information needed to do this, but it is the duty of every member of the team, including support workers, to create a culture where this is the norm.
Since the publication of Changing Childbirth (Department of Health, 1993) there has been a succession of government and other influential reports making specific reference to choice, both in general healthcare and maternity services. Reports such as The National Service Framework for Children, Young People and Maternity Services (DH and DfES, 2004) and High Quality Care for All (Darzi, 2008) illustrate the main forces governing the settings and contexts in which health care workers operate, and in which childbearing choices are made.
One of the most important government reports related to childbearing is Maternity Matters (DH, 2007) which emphasises the flexible, personalised service that every woman must have to meet her individual needs. The report made a number of ‘national choice guarantees’. These were:
- Choice of how to access maternity care
- Choice of type of antenatal care
- Choice of place of birth
- Choice of postnatal care.
A number of recent policy developments have had significant impact on the provision of midwifery services. The European Working Time Directive(EWTD), introduced in August 2009, limits the number of hours a junior doctor is permitted to work per week (DH, 2009). This has inevitably reduced the amount of experience junior doctors are able to gain in obstetrics and the number of hours they can amass before becoming consultants. Consequently, midwives are taking on some of the roles formerly undertaken by doctors, such as intravenous cannulation and full newborn examination. The effect of this has been that some traditional midwifery roles, such as breastfeeding support, are being taken on by other healthcare workers, such as MSWs (Griffin, 2009). This shift has led to a loss of role clarity and concerns over whether ‘role substitutors’ have the right educational background to execute the role to the necessary high standards (Tooke, 2008).
The current shortage of midwives in England means recruitment drives and return to practice programmes are high on the midwifery workforce agenda (Royal College of Midwives, 2008). Nationally, heads of midwifery and lead midwives for education have collaborated to review commissions for both undergraduate and postgraduate midwifery training. Some midwives have been reluctant to pass on midwifery duties to other workers. However, with an increasing birth rate in the UK (Office for National Statistics, 2008) an increase in complex care and delivering the Maternity Matters agenda, it is timely to explore roles that can be moved from midwives to support staff (DH, 2007).
The West Midlands
Historically, the national maternity workforce has been made up of midwives, general practitioners, obstetricians and auxiliary workers. Midwives make up the greatest proportion and 2,771 midwives notified their intention to practise in the West Midlands in 2008 (Kuypers, 2008).
Between 2002 and 2008, the annual birth rate across the West Midlands increased by 7,000 each year (Kuypers, 2008). This increase equates to more than the number of births each year in one large maternity unit in the West Midlands, or in several midwifery led units around the region. At present there are about 520 whole time equivalent (WTE) midwives working in community settings across the West Midlands, with establishments ranging from 15.0 to 52.61 WTEs. These figures directly relate to the number of births per year and the type of care available in each trust. Maternity service provision in the region varies enormously, accommodating between 1,659 and 6,176 births a year in hospitals and between 173 and 1,367 births a year in midwife-led units. Home births range from 13 to 139 per year - 0.4 to 3.7% of the total annual births (Kuypers, 2008). These figures demonstrate the varied patterns of work for midwives throughout the region. The population has also become more diverse, and these changes have had a significant impact on midwives and maternity services in the area. Planning the workforce to meet the demands of maternity services is becoming increasingly difficult for commissioners.
To gain a full picture of childbirth choices across the West Midlands, and the implications for the future education and training of healthcare workers, a literature review was commissioned in 2008 by the Workforce Deanery of NHS West Midlands. This was conducted by a team from the Faculty of Health and Life Sciences at Coventry University and the University Hospitals Coventry and Warwickshire NHS Trust. The literature suggested that both intrinsic and extrinsic factors influence the ability of women to make choices during childbirth. Intrinsic factors included the characteristics of the women themselves, many of which cannot be changed. Extrinsic factors are the outside influences on childbearing women, including the knowledge and attitudes of healthcare professionals and the policies of the institutions in which they operate. These are factors which potentially could be changed.
The review also found that new roles were being taken on by health care workers and services were being commissioned and funded in new ways.
Maternity Support Workers
There have been many suggestions on the future role of the MSW. The National Service Framework for Maternity Services (DH and DfES, 2004) stated that MSWs should have important roles in future maternity care, for example working in postnatal areas under the supervision of midwives. In 2006, the Department of Health commissioned work to examine the role that support workers could play in maternity services. The role was again referred to in Maternity Matters in reviewing the skill mix to release the clinical time of other staff, with examples of roles in clerical work, breastfeeding support and parent craft classes (DH, 2007).
NHS Employers (2006) reported on a large scale workforce change programme in which models of the role of the MSW were explored with a view to the dissemination of good practice. Maternity support worker roles had been developed or were being implemented across 55 NHS trusts in 26 strategic health authorities. Two hundred and eighteen whole time equivalent (WTE) posts were implemented over a 10 month period. The report gave demographic and outcome data for each trust. This included where the MSWs were delegated to work, the range of roles being undertaken, the improvements being delivered for women and the maternity team, and the impact on midwifery time being saved and the views of users and staff (table 1).
The report showed that significant numbers of midwifery hours were being released in both acute and community settings. Reported benefits included midwives being able to spend more time with women in labour on a one-to-one basis and being able to update professionally. Views of childbearing women were positive, midwives were less pressured and MSWs felt valued and satisfied with their new roles (NHS Employers, 2006).
Stout (2007) described fourteen examples of how the MSW role has developed in maternity services in England. One of these, a birth centre in St Austell, Cornwall, provided additional training for MSWs to enable them to take on roles such as breastfeeding support and new baby care, both in the birth centre and the community. In this instance, choice for women has been supported through more efficient use of staff resources and increasing the viability of a midwife-led community based service. This has also allowed flexible appointments for women including evenings and weekends. Other new roles taken on by support workers and described in the report include clerical and administration duties, extra support in labour and parent education.
Sandall et al (2007) surveyed a 50% representative sample of maternity trusts in England to examine the numbers, scope and range of practice, skill mix and service model arrangements of support workers in maternity services. Using a telephone questionnaire, the researchers interviewed 94 maternity unit managers. Analysis of the data showed a wide variation in the range of activities being undertaken by support workers, including housekeeping duties, booking appointments, neonatal blood tests and abdominal examination. However, the employment bands awarded varied and support workers carrying out similar roles were often being paid at differing rates.
In January 2009 NHS West Midlands funded a project to enable MSWs to take over the scrub role in the obstetric theatre. An in-depth theoretical and practical programme has produced high quality, trained workers which has released midwives and registered nurses from the scrub role. The project is ongoing and other areas have also adopted this position. MSWs are being developed to act as a second person at a home or hospital birth (with the midwife remaining accountable for care) or to provide enhanced breastfeeding support and support to the community midwifery service (NHS Employers, 2006).
An evaluation of a 2006 rapid rollout programme in South East England found the MSW to be an invaluable addition to maternity teams (NHS Employers, 2006).
Midwives need to delegate some of the roles that can be undertaken by those without a professional midwifery qualification, and MSWs need to develop additional skills to take on these roles. However, the rapid development of the MSW role has led to some anxiety among midwives. There is concern that their role might be eroded and they could be replaced by a cheaper alternative (Ackerman and Maycroft, 2008). Clarification of the responsibilities of the maternity support worker and their interface with the statutory role of the midwife is therefore required. Additionally, while midwives are required to work within a professional code there is currently no regulation of support workers. This raises issues of accountability which require further debate.
Changes due to the EWTD and national policy have expedited the need for health professionals to review their roles. Midwives and nurses have enhanced and developed their skills over the last decade but they remain reluctant in part to give up traditional tasks that can be done by others. The increased birth rate, diverse population and the need to implement national policy mean midwives need to embrace the assistance of well trained support workers. Whatever the job title - maternity support worker, maternity care assistant or maternity assistant (Stout, 2007) – the support worker role is seen as essential to the future of maternity services and in enabling midwives to make choice a reality for childbearing women.
Ackerman B, Maycroft L (2008) Maternity support workers: here to stay. The Practising Midwife; 11: 8, 15-17.
Darzi A (2008) High Quality Care For All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2009) What is the European Working Time Directive?London: DH.
Department of Health and Department for Education and Skills (2004) National Service Framework forChildren, Young People and Maternity Services. Maternity Standard. London: DH.
Department of Health (2007) Maternity Matters: Choice, access and continuity of care in a safe service. London: DH.
Department of Health (1993) Changing Childbirth (part I): Report of the Expert Maternity Group. London: HMSO
Griffin R et al (2009) Building capacity to care: learning for maternity support workers. British Journal ofMidwifery. 17: 1, 7-11.
Kuypers B (2008) The Local Supervising Authority Midwifery Officer Annual Report April 2007-March 2008. Birmingham: The West Midlands Local Supervising Authority.
National Institute for Health and Clinical Excellence (2008) Antenatal care: Routine care for the healthy pregnant woman. London: NICE.
NHS Employers (2006) Maternity Support Workers: enhancing the work of the maternity team. National Large Workforce Change. London: NHS Employers.
Office for National Statistics (2008) National Statistics Online – Live Births. London: ONS.
Royal College of Midwives (2008) The quality of maternity care, staffing levels and pay top the table of midwives’ woes. London: RCM.
Sandall J et al (2007) Support workers in maternity services: a national scoping study of NHS trusts providingmaternity care in England 2006: final report. London: King’s College London, Florence Nightingale School of Nursing and Midwifery.
Stout J (ed) (2007) Innovations Matter: Examples of Support Workers in Maternity Services. Bristol: Care Services Improvement Partnership.
Tooke J (2008) Aspiring to Excellence: Final Report of the Independent Inquiry into Modernising Medical Careers. London: MMC Inquiry.