National Institute for Health and Clinical Excellence (NICE)
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One midwife to each woman during birth, says NICE in safe staffing advice

In its second guideline for safe staffing in the NHS, the National Institute for Health and Care Excellence (NICE) gives advice on how to make the right decisions about midwifery staffing levels for women and their babies, wherever they choose to go.

Professor Gillian Leng, deputy chief executive and director of health and social care at NICE said: “From planning  to have a baby, to giving birth and the days after, the care provided by midwives has a lasting impact on a woman’s wellbeing , and on the health of her baby. This new guideline provides evidence-based advice to the NHS on how to ensure midwifery staffing is safe in whichever setting a woman may choose, be it at home, in the community or in hospital.”

The new recommendations set out responsibilities of senior managers and actions organisations should consider as part of their midwifery staff planning, as well as how registered midwives on a shift should monitor whether there are sufficient staff to provide safe care for the needs of women and babies.

It calls for commissioners, hospital boards and senior management to focus on the needs of each woman and baby and ensure there are enough midwives employed to provide safe care, regardless of the time of day or the day of the week.

The guideline provides step-by-step guidance for organisations to work out the number of midwives required including making sure that local records are used to help predict requirements and any potential variations in demand. Hospital boards are accountable for the final staffing decisions but the guideline recommends how management should best work alongside senior midwives when making staffing decisions.

The committee recognised that giving birth can be associated with serious safety issues and in order to ensure that a woman has a safe experience of giving birth, the guideline recommends that women in established labour1 should receive supportive one-to-one care.

Miles Scott, chief executive, St George’s University Hospitals and chair of the committee that developed the guideline said: “Maternity services must focus on planning midwife care adequately in advance to ensure women, babies and their families all receive the midwifery care they need. This new guideline sets out a systematic process to follow to decide how many midwives need to be employed whilst allowing for flexibility to respond to fluctuating demand.

“Following the recommendations will help services put appropriate plans in place so they can confidently and consistently provide safe care and suitably respond to changing demands.”

The guideline includes recommendations for appropriate escalation plans as a safety net to respond to unexpected changes in demand. These include sourcing extra staff, redistributing midwives’ workload to other competent staff or rescheduling non-urgent work. However, it stresses that any action taken must not be at a detriment to other areas and that service closures should only be considered as a last resort.

For senior midwives, the guideline recommends regularly monitoring positive and negative events which can provide information on whether staffing is adequate. This can be done using data already being routinely collected such as appointments being booked on time, mothers given help with breastfeeding or staff reported events like missed breaks and overtime.

The guidance also highlights warning signs for patients and hospital staff to identify when there may be too few midwives on hand. These ‘midwifery red flag events’ can include if a woman waits more than an hour for stitches or to be washed after giving birth, or is not provided with the medicines she needs following admission. Red flag events should be notified to the midwife in charge to determine whether any action is needed. 

Jane Hervé, head of midwifery, Oxford University Hospitals NHS Trust and a member of the committee that developed the guideline said: “Providing safe care for every woman and baby is at the heart of what every midwife does each day. The guideline and supporting information is important and will help inform day-to-day decisions about how many midwives are needed so that women across the country know they will receive the support and care they need. The use of the NICE endorsed toolkits, once they become available, will help determine midwifery staffing requirements. This guideline is an important first step and with the calls it includes for further research it will help continue to develop what we know about safe midwifery care.”

Cathy Warwick, chief executive officer, Royal College of Midwives: “I welcome this guidance, which should help to ensure that maternity services have safe staffing levels that are monitored on a regular basis and are adjusted according to local need.  The report highlights the vital importance of ensuring adequate staffing in the antenatal and postnatal periods, as well as in labour.

“I am very glad that the guidance focuses primarily on the needs of women and babies, and the importance of making time to give them individualised care; this will help ensure women and babies get the care they deserve.”

NICE has produced a separate report which looks at the potential impact that implementing the guideline may have on NHS resources. Precise estimates of the cost of the guideline nationally are very difficult to produce because safe staffing practices are already being made and because it is difficult to estimate the current cost of midwife staffing across the country.

The report estimates a headline additional cost of £4 million could be incurred to implement the one-to-one ratio, however if all current vacant midwife posts are filled this could well be less or even zero3.

Professor Leng added: “Following on from the Francis and Keogh reports we know that maternity services in the NHS have already started putting safer staffing practices into place. Since the publication of the Department of Health report, Maternity Matters in 2007, the number of midwives in post has been growing by 3% on average each year and the training numbers for midwives also continues to increase.

“Implementing this guideline may not have a significant financial impact in many areas, particularly once all planned vacant posts are filled and there is little requirement for temporary staff. The recommendations provide guidance on how maternity services can make the best use of midwife staff at any given time to ensure the needs of each woman and baby are being met.

“The benefits of better care in maternity services, such as costs savings that could be achieved from reducing readmissions and postnatal depression or dealing with fewer complications at birth, make safe care worth investing in.”

This guideline was commissioned by the Department of Health and NHS England in November 2013 and is part of a series of guidelines which NICE will develop on safe staffing in the NHS, with a particular focus on nursing and midwifery.

NICE has also issued separate information for members of the public to explain the guideline and help make sure they know what they can do if they feel there are not enough midwives available.

Further details of all published and upcoming safe staffing guidelines are available on the NICE website.

For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.

Notes to Editors

Further information

  1. Established labour is when there are regular and painful contractions, and the cervix has opened to at least 4 cm.
  2. The final guideline is available at /guidance/ng4.
  3. The final resource impact commentary is available at/guidance/ng4/resources.                                                                          

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

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