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Title: Association between mode of birth, staffing and structural characteristics in NHS trusts with maternity services in England (2010/11)
Author: Gerova, Vania Nikolova
ISNI:       0000 0004 5368 2607
Awarding Body: King's College London
Current Institution: King's College London (University of London)
Date of Award: 2014
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Background: Growing international research evidence, mainly from the acute general service sector, suggested that there was a strong link between nurse staffing and patient outcomes. There was a gap in the literature addressing other clinical and non-clinical workforce groups outside acute hospitals. Aim: To investigate the relationship between mode of birth and maternity staffing levels in NHS trusts in England, after accounting for maternal socio-demographic characteristics, individual clinical risk and structural characteristics including type and configuration of trusts. Method: This cross sectional study used Hospital Episode Statistics (HES) 2010/11 and NHS Information Centre 2010/11 maternity workforce datasets. The study population comprised women aged 15-45, who were nulliparous and had a term, singleton, live birth (n=261,481 deliveries in 143 NHS trusts for emergency caesarean section and instrumental deliveries; and n=214,920 deliveries in 127 NHS trusts for normal birth). Multilevel logistic models were fitted separately for each outcome. Risk-adjustment for case mix included maternal age, ethnicity, IMD, gestational age, birth weight and NICE 2007 derived definition of clinical risk. Standardized FTE/birth ratios for obstetricians, midwives, healthcare assistants and other trust characteristics were used as trust level predictors. The percentages of the total variation in outcomes attributable to between trusts variation were calculated. Results: For this sample of women only around 2% of the residual variation in outcomes was due to unobserved trust characteristics. Between trusts and for all women, the standardized consultant FTE/birth ratio was positively related to the probability of instrumental delivery (OR=1.08, 95%CI 1.03-1.13, p < .05), and the standardized midwives FTE/birth ratio was positively related to the probability of normal birth (OR=1.06, 95%CI 1.01-1.11, p < .05). 1 SD increase in FTE doctors increased the odds of emergency CS for high risk women by 5.1% (OR=1.05, 95%CI 1.01-1.10, p < .05); while 1 SD increase in FTE midwives increased the odds of normal birth for low risk women by 7.6% (OR=1.08, 95%CI 1.02-1.14, p < .05). Conclusion: The analyses established significant independent effects of staffing on the three outcomes, although only a small percentage of the total variability in the outcomes was attributable to variations between trusts. The positive association between midwifery staffing and normal birth has policy implications in terms of current and future investment in the profession. More than anything else, women’s outcomes were determined by their characteristics and clinical risk. Other unaccounted for factors such as obesity, smoking, organisational culture and models of care may be able to explain further the variations in outcomes.
Supervisor: Bick, Debra Elizabeth ; Griffiths, Peter Donald ; Cookson, Graham Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available