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Counting the cost of UK maternity wards

Midwives’ decisions can determine the level of care expectant mothers receive

By Nicos Savva . 03 May 2017

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Midwives’ decisions can determine the level of care expectant mothers receive



As any civilised society would agree every mother and baby deserves the very best care.  Programmes such as ‘Better Births’ has helped to provide a blueprint for improved maternity services.  Another area of support revealed by new research is demonstrating that cost savings can be made by introducing flexible staffing levels to maternity wards.

“Giving birth is one of the most frequent reasons for hospitalisation, so a significant amount of the NHS budget is spent on maternity wards,” says Nicos Savva, Associate Professor of Management Science and Operations at London Business School (LBS). His paper ‘Gatekeepers at Work: An Empirical Analysis of a Maternity Unit’ finds that the decisions midwives make when assisting women in labour can have big cost implications without affecting patient outcomes. It also shows that the level of care given is dependent on workload.

The research, co-authored by Michael Freeman and Stefan Scholtes from Judge Business School, University of Cambridge, explores whether staff cuts at a UK hospital have affected how women in labour are treated. Moreover, it provides insight into the role of midwives in providing care and the associated costs.

Midwives are in a position to influence the type of treatment an expectant mother receives when giving birth. For example, they have significant influence on the decision to prescribe an epidural – a pain-relief injection in the small of the back that numbs the lower abdomen – which has to be administered by an anaesthetist. Midwives also decide whether to get a physician involved in the delivery.

Bringing in a specialist to administer an epidural is more expensive than other forms of pain relief that can be provided by a midwife, such as gas. The costs also rise when a physician is involved in the delivery (e.g. to help deliver the baby using forceps or suction cup, or to perform a C-section). 

“What’s intriguing is that the midwife assigned to a mother giving birth acts as both the care provider and the gatekeeper to specialist resources such as physicians who can complete the delivery,” Dr Savva says. “You want patients to be seen by the most capable resource; the problem is that resource is expensive, so you need a gatekeeper. If everyone went to the most specialist resource, you’d have a super-expensive healthcare system.”


The effect of workload on decision making


Dr Savva and his co-authors have discovered a link between the decisions that midwives make and how busy they are. The research shows they manage their workload in two ways. First, they typically prescribe fewer epidurals during busy periods, particularly to mothers who are less likely to experience complications in childbirth. “Around a quarter of mothers who would normally have an epidural in a quiet period do not receive them when their midwife is really busy,” Dr Savva says.

Second, the workload can also determine whether women in labour are referred to physicians. Midwives are more likely to call on these specialists in busy periods rather than quieter spells. Dr Savva says: “You find that around 15% of the mothers who are referred to a physician when it gets busy wouldn’t receive the same treatment if the midwife had a more relaxed workload.”

He adds: “Our research is consistent with overtreatment during quiet spells in the delivery unit, because more epidurals are administered and, as a result, deliveries become more expensive.  Our work is also consistent with overtreatment during  busy periods as well. Expectant mothers are over-referred to specialists, which also leads to increased costs.”

Introducing more flexible staffing could help eradicate busy and quieter periods which could help reduce overtreatment and possibly keep costs down, according to Dr Savva. “Our findings have implications for staffing,” he says. “The demand is hugely variable depending on the number of expectant mothers in a maternity ward at any given time, but hospitals tend to have a fixed number of staff. There are days when the same number of midwives look after 20 to 25 women and others with only four to five on the ward.

“Ideally, hospitals need a flexible supply of midwives to better match demand. This approach could prove expensive to implement, but I believe it would provide a more consistent patient experience and partially pay for itself in the long term as you’d eradicate the costs associated with busy and quiet spells.”

Midwives’ decisions can determine the level of care expectant mothers receive

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