Hazards of understaffing

Joanne Robertson, Westmead Hospital NSWNMA Branch delegate
Joanne Robertson, Westmead Hospital NSWNMA Branch delegate

Westmead’s understaffed maternity ward struggled to provide safe care. Now patient complaints are down and staff satisfaction is up.

By 2011, Westmead Hospital’s 41-bed maternity ward was seriously understaffed.

Birthrate Plus calculations showed that morning shift needed 11 midwives but usually had only eight. Night shift needed nine midwives but mostly had to make do with four or five.

“It was risky especially at night,” said NSWNMA delegate Joanne Robertson. “You only needed one baby to deteriorate or a lady to bleed and it became quite hazardous.

“Many of our women need a lot of attention because they have issues like high blood pressure, or are new mothers, or are from non-English speaking backgrounds – or a combination of all these factors.

“Being understaffed in these circumstances was very stressful, which led to more sick leave, which meant more overtime to make up.

“We often had to work short because they couldn’t find a replacement or they could only send us non-midwifery staff.

“We just didn’t have the staff to properly educate the women and help them with things like breastfeeding.”

Joanne says the hospital’s NSWNMA branch used Birthrate Plus calculations to prove to management that the maternity ward needed more staff in order to raise safety standards and meet service goals.

The ward’s acting Midwifery Unit Manager, Carolyn Tranter (pictured above), says the recent staff increase has brought the unit close to its Birthrate Plus requirements.

“We are busy training a very enthusiastic bunch of new graduates,” she said. “Previously we didn’t have the time to give enough attention to students doing their graduate diploma of midwifery or bachelor of midwifery.”

A recent staff survey showed a high level of satisfaction on the maternity ward.

“You would have got a different response a couple of years ago,” Carolyn said.

She said the staff increase had also sharply reduced the number of patient complaints about problems such as unanswered bells or lack of assistance with breastfeeding.

“We are able to spend much more time with the women which is so important for a high risk referral hospital with acuity in the maternity ward.

“The midwives say they now have time to talk to the women instead of just running around putting out fires as they used to.

“They are much less stressed and enjoy their jobs more.”


Birthrate Plus is designed to capture the acuity of patients and the tasks performed in caring for them – not just raw numbers.

There are two separate forms – one for labour and another for assessments.

The form for labour records the date and time in and out of the birthing unit.

Section A looks at gestation and what happened during labour. The midwife records the gestation of the pregnancy, duration of labour, what interventions were used, the number of babies, and whether the mother had co-morbidity such as diabetes, mental health problems or drug and alcohol problems.

Section B examines delivery. The midwife notes whether it was a normal birth, an instrumental birth, an elective caesarean or an emergency caesarean.

In Section C the midwife records information about the perineum – the degree of perineal trauma that was sustained intrapartum.

Section D relates to the baby – the Apgar score, weight, whether the baby needed resuscitating, admission to NICU or special care nursery, the presence of congenital abnormality or stillbirth.

Section E records other intensive care such as blood transfusion, emergency anesthetic, or IV infusion.

The midwife calculates a score for each section and then a total. These are categorised from one to five with five being the worst.

Westmead Hospital’s most recent use of Birthrate Plus in the birth unit took three months to complete.

Acting Midwifery Unit Manager Candace Everard says Westmead has a high number of category 4 and 5 cases.

“Birthrate Plus demonstrated an increase in acuity over the previous survey which strengthened our case for additional staff,” she said.

“It’s a really good tool and with a bit of education it doesn’t take long for a midwife to fill out the form.”