One of the great things about being a midwife is the privilege of sharing the miracle of new life. The role of the midwife and the uniqueness of the dynamic relationship with women may be immeasurable because of the unseen relational advocacy and partnership empowerment. Safeguarding the holistic role of the midwife at a time when austerity forces efficiency gains has never been more important. Equally, providing high-quality maternity services against a backdrop of a predicted £44–54 billion funding gap by 2020/21 (Roberts et al, 2012) presents challenges for providers, particularly as health policy expects improvement in quality and workforce models that put service users first and offer them choice in their health care (NHS England, 2014).
There were 695 233 live births in England and Wales in 2014, down 0.5% from 698 512 in 2013 (Office for National Statistics, 2015). Despite this small decrease, overall births are at their highest in 40 years (NHS England, 2014). Financial pressures suggest it is unrealistic to expect significant increases in staff numbers, so provider units have responded in a number of ways.
- The introduction of neonatal nurse practitioners in some maternity units enables tasks such as transitional care for babies to be undertaken by nurses, thus releasing midwifery time. Some units employ theatre nurses to manage and lead obstetric theatres, scrub for caesarean section cases and work in maternity high-dependency units. While there is no published evidence regarding the impact of these roles on service outcomes, employing appropriately trained nurses instead of midwives implies that the hospital would be making a cost saving.
- To release midwifery time to focus on midwifery practice, the maternity support worker (MSW) role has been developed. This allows an appropriately trained MSW to undertake tasks delegated by a midwife to care for women and families (Department of Health, 2004; 2007). Evaluation of the MSW role shows they are supporting midwives and doctors to improve service delivery; however, there is limited evidence regarding efficiencies these roles create.
- Some NHS Trusts have introduced postnatal community-based clinics, where women are invited to attend for routine postnatal care rather than receive home visits by a community midwife; again, there is an absence of empirical evidence of benefit. It is postulated that postnatal clinics create workforce efficiencies by reducing the need for low-risk postnatal women to be visited at home. This may release midwives to support more women in the postnatal clinic because of a reduction in travelling time. Frequently, MSWs assist midwives at clinics; for example, by supporting women who may have practical queries about aspects of infant care. This reduces contact time between woman and midwife. However, without formal evaluation of the safety and efficiency of postnatal clinics, or of women's views to assess whether they find this model of care appropriate for their individual needs, the impact of this service is difficult to elicit.
- The telephone helpline has been implemented in some maternity units to increase productivity and efficiency. This provides women booked for maternity care at the unit with direct access to a midwife, from whom they can get information and advice about their pregnancy or post-birth care. The helpline midwife has the potential to empower pregnant/postnatal women, where appropriate, to take care of their own health concerns that may not require direct midwifery contact, reducing the need for unscheduled appointments or hospital admission. Few maternity units have introduced a dedicated helpline available for callers regardless of their stage of pregnancy alongside routine care provision. There is a dearth of evidence on whether the advice offered by a helpline midwife avoids an unscheduled appointment or hospital admission, or whether providing a helpline affects the working practice of members of the health-care team.
Creative thinking and meticulous planning, including evaluation, are required when introducing new roles and services to the maternity portfolio. The introduction of safe workforce models that put service users first, and offer them a say in their health care, is of paramount importance. However, for true success and a degree of financial stability, this must be supported by tariff-based NHS funding.