UK Health & Social Care System, Birth Settings, Safe Staffing & Keeping Mothers and Babies Together

UK Health & Social Care System, Birth Settings, Safe Staffing & Keeping Mothers and Babies Together

Midwives work across many settings and organisations. The Future Midwife standards expect them to understand the health and social care system and the settings for maternity care (2.1), the different ways of organising care (2.2), the factors affecting safe and effective services (2.3), and how to work across settings to provide continuity (2.4). They must coordinate care and arrange seamless transfer when midwifery care is shared or handed over (2.11), and keep mothers and newborn babies together whenever possible, even when complications occur (2.6, 4.10).

---

The Health and Social Care System

Health care is a devolved responsibility, so each UK nation organises its services differently:

Within maternity care:

• Primary and community care includes GPs, community midwives and health visitors. In England, health visiting is part of local authority-commissioned public health services for children aged 0 to 19.
• Secondary care includes hospital maternity units, obstetric units and special care baby units.
• Specialist (tertiary) care includes fetal medicine units and neonatal intensive care units (NICUs). Neonatal units are organised in operational delivery networks with three levels: special care units, local neonatal units and NICUs.
• Social care is provided by local authorities, including children's social care, which leads on safeguarding.
• Maternity and Neonatal Voices Partnerships (MNVPs) bring women, families and staff together to review and improve local services.

---

Settings for Birth and Planning Place of Birth

Women may plan to give birth at home, in a freestanding midwifery unit (FMU), in an alongside midwifery unit (AMU) on a hospital site, or in an obstetric unit (OU). NICE NG235, drawing on the Birthplace in England study, advises:

• Low-risk multiparous women: planning birth at home or in a midwifery-led unit (freestanding or alongside) is associated with fewer interventions, and the outcome for the baby is no different from an obstetric unit.
• Low-risk nulliparous women: planning birth in a midwifery-led unit is associated with fewer interventions and no difference in outcome for the baby. If they plan birth at home, there is a small increase in the risk of an adverse outcome for the baby.
• Body mass index: the higher the BMI at booking (particularly above 35 kg/m²), the greater the likelihood of complications, which women may wish to consider when planning place of birth.

Women are also told how likely transfer is and why it may happen. In the Birthplace data, delay in the first or second stage of labour was the most common primary reason for transfer from home, an FMU or an AMU, followed by reasons such as meconium staining, abnormal fetal heart rate, requests for regional analgesia, perineal repair and retained placenta. Nulliparous women are much more likely to transfer than multiparous women.

Transfer of Care

When care is transferred, the midwife acts as coordinator of care:

• Explains the reason for transfer to the woman and her birth companion and gains her agreement.
• Arranges transport (ambulance for urgent transfers) and accompanies the woman where appropriate.
• Gives a structured SBAR handover to the receiving team, with the records.
• Ensures the woman's preferences, such as skin-to-skin contact and feeding plans, travel with her, and that the baby's needs are considered alongside hers.

---

Ways of Organising Midwifery Care

Different models of care affect safety, women's experiences and staff:

• Midwifery continuity of carer (caseload or small team models): a known midwife or small team provides care through pregnancy, birth and the postnatal period. Evidence shows more spontaneous births, fewer interventions and more positive experiences (see the continuity of carer section).
• Team or shared care: community midwives and GPs share antenatal care, with hospital teams providing intrapartum care.
• Consultant-led care: for women with medical or obstetric complications, obstetricians lead the plan while midwives provide midwifery care and continuity where possible.
• Midwife-led care: for women at low risk, the midwife is the lead professional throughout.

Expanding continuity models depends on safe staffing. National plans in England, such as the three-year delivery plan for maternity and neonatal services (2023), state that continuity should be rolled out only when staffing allows.

---

Factors Affecting Safe and Effective Services

Safe maternity care depends on more than individual skill. Key factors include:

• Staffing and skill mix: NICE NG4 (Safe midwifery staffing for maternity settings) advises one-to-one care in established labour and lists midwifery red flags that suggest staffing is unsafe. Examples include being unable to provide continuous one-to-one care in established labour, a delay of more than 30 minutes in giving pain relief, a delay of 30 minutes or more between presentation and triage, and delayed recognition of or action on abnormal vital signs. Red flags are reported and escalated to the midwife in charge.
• Workforce planning tools such as Birthrate Plus estimate the number of midwives needed for the local case mix.
• Teamwork and culture: civility, multidisciplinary training and clear escalation pathways.
• Environment and equipment: well-maintained, checked emergency equipment and birth environments that support physiological birth.
• Regulation and incentives: the Care Quality Commission inspects services in England, and the NHS Resolution Maternity Incentive Scheme rewards trusts that meet its safety actions.
• Listening to women and families: complaints, MNVP feedback and national surveys help services improve.

---

Keeping Mothers and Babies Together

Separating a mother and baby disrupts skin-to-skin contact, breastfeeding, bonding and maternal confidence. Midwives use evidence-based approaches to keep them together whenever possible:

• ATAIN (Avoiding Term Admissions Into Neonatal units): a national programme in England that reviews term admissions to neonatal units. The commonest avoidable reasons include respiratory problems, hypoglycaemia, jaundice and hypothermia. Good thermal care, early and frequent feeding, and following hypoglycaemia pathways prevent many admissions.
• Transitional care: babies with additional needs, such as late preterm babies who are stable, babies needing phototherapy, some babies on IV antibiotics, or babies needing extra feeding support, can be cared for alongside their mother on the postnatal ward or in a transitional care area, with support from neonatal staff, rather than being admitted to the neonatal unit.
• Family integrated care: when admission is necessary, parents are supported to be partners in care, with skin-to-skin (kangaroo) care, expressing breast milk and involvement in ward rounds.
• The sick mother: if the mother is in high dependency or intensive care, the baby can often stay with her, or visits and skin-to-skin contact are arranged as early as possible, with breast milk expression supported.

Throughout, the midwife continues to provide midwifery care while working with obstetric, neonatal, anaesthetic and social care colleagues (4.9).