Capacity Planning (Capital, Staff and Costs) of Inpatient Maternity Services: Pitfalls for the Unwary
Abstract
:1. Introduction
2. Materials and Methods
2.1. Data Sources
2.2. Hospital Episode Statistics
2.3. Additional Bespoke Data
2.4. Estimating Real-Time Length of Stay (LOS)
2.5. Variability in the Gender Ratio
3. Results
3.1. Trends in Available Beds in England
3.2. Assessing Current Bed Sufficiency Using Average Bed Occupancy
3.3. Seasonality in Births and Bed Demand
3.4. Circadian Profiles
3.5. Forecasting Births
3.6. Trends in Admissions Relating to Pregnancy and Childbirth
3.7. Effect of the Environment on Neonatal and Congenital Conditions
3.8. An Impending Maternity Crisis?
3.9. A Survey of Capacity Preparedness in England
- Are they aware that the reported bed occupancy at the obstetric unit is higher than may be expected for their size?
- Has any National or Professional Society guidance ever been published on how to correctly size a maternity unit?
- Do they have any planning documents relating to the choice of the current number of maternity beds?
4. Discussion
4.1. General Issues
4.2. Forecasting Long-Term Trends in Births
4.3. Seasonality in Births
4.4. 24-h and Weekday Cycles in Bed Occupancy
4.5. Lunar and Solar Cycles
4.6. Infections and Pregnancy
4.7. Risk Factors
4.8. The English NHS National Maternity Review
4.9. Issues of Population Density and Distance
4.10. Does Decreasing Length of Stay (LOS) Actually Reduce Costs
“This is because for both medical and surgical patients, the main costs occur in the first half of the stay when input from staff, investigation, and intervention are at a maximum. Stays in hospital are almost always shortened by reducing lower dependency “cheaper” days, usually in the second half of the stay”. Along similar lines another study noted that “not all hospital days are economically equivalent”[105]
- How are direct maternity costs allocated based on time? Is time-based costing used?
- How are wider hospital overhead costs allocated to the maternity department, and would a change in the apportionment method used for each function have a significant effect on the supposed ‘cost’?
- How do costs behave over time (fixed and variable costs, marginal costs, step increases/reduction due to changes in demand)?
4.11. Pitfalls in Benchmarking Length of Stay (LOS) and Costs
“Reducing the length of time women spend in hospital after birth implies that staff and bed numbers can be reduced. However, the cost savings may be reduced if quality and access to services are maintained. Admission and discharge procedures are relatively fixed and involve high cost, trained staff time. Furthermore, it is important to retain a sufficient bed contingency capacity to ensure a reasonable level of service. If quality of care is maintained, staffing and bed capacity cannot be simply reduced proportionately: reducing average LOS on a typical postnatal ward by six hours or 17% would reduce costs by just 8%. This might still be a significant saving over a high volume service however, earlier discharge results in more women and babies with significant care needs at home. Quality and safety of care would also require corresponding increases in community based postnatal care. Simply reducing staffing in proportion to the LOS increases the workload for each staff member resulting in poorer quality of care and increased staff stress.”
4.12. When Did England Reach the Optimum LOS?
“The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of problems and to ensure that the mother is sufficiently recovered and prepared to care for herself and her newborn at home. The LOS should be based on the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the newborn, the ability and confidence of the mother to care for herself and her newborn, the adequacy of support systems at home, and access to appropriate follow-up care in a medical home. Input from the mother and her obstetrical care provider should be considered before a decision to discharge a newborn is made, and all efforts should be made to keep a mother and her newborn together to ensure simultaneous discharge”[115]
4.13. Matching Staffing with Demand
4.14. Size, Statistical Chaos and Income
4.15. Fair Funding for Maternity Units
4.16. Flexible Staffing to Offset the Efect of Size
4.17. A System-Wide View of Maternity Costs
4.18. Key Recommendations
- Government health departments should encourage the use of turn-away for understanding maternity unity capacity preparedness.
- There is reliable evidence that maternity demand is subject to hourly, seasonal and environmental fluctuations, implying that the annual average occupancy should ideally be below 0.01% turn-away.
- Any maternity unit with an annual average turn-away greater than 1% must flag this on the hospital risk register and implement plans to correct this situation.
- Research is required to disentangle the effects of turn-away and poor staffing on safety and outcomes in maternity units.
- Maternity units should monitor bed occupancy and associated turn-away hourly throughout the year in the birthing unit, the postpartum maternity unit, any associated maternity (short stay) assessment unit and any Midwife-led community units. Past trends in such metrics should also be investigated to determine the local fluctuations in demand and ongoing trends. A chart showing daily admissions or births over many years is always a helpful tool.
- Maternity units should refresh their estimates of future demand every two to three years and compare how actual demand compares with past estimates.
- Government regulators should establish guidelines regarding the maximum acceptable turn-away in maternity units.
- Benchmarking of maternity unit minimum acceptable LOS needs to be against nationally agreed levels of quality and safety. High turn-away units should be excluded from the derivation of such benchmarking.
- To compare costs on a like-for-like basis, the cost per HRG/DRG requires the identification of the separate components of cost, namely, depreciation on capital (buildings and equipment), organization-wide apportioned costs for all the non-patient facing departments and the direct costs of care. The direct costs of care per birth will be higher as the unit gets smaller and, on this basis, small midwife-led low risk units are unlikely to be cost effective—although they may be considered desirable by mothers.
- In England, which uses the HRG tariff, all maternity units should receive extra funding based on size to mitigate the unavoidable higher costs relating to smaller size.
- Research is required as to how maternity units cope on days when there are unusually high births arising from Poisson variation, i.e., do they resort to emergency C-section to cope? Due to the skew in the Poisson distribution, this becomes a bigger problem as the unit gets smaller.
- As an extension of #11, the safe staffing levels for maternity units must be formulated with a higher ratio as size decreases.
4.19. Limitations of the Study
5. Conclusions
Supplementary Materials
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
Country of Birth of Mother | 2001 TFR | 2011 TFR | Country of Birth of Mother | 2001 TFR | 2011 TFR |
---|---|---|---|---|---|
North Africa | 4.6 | 3.9 | New EU | 2.0 | 2.2 |
Pakistan | 4.7 | 3.8 | Central Asia | 2.7 | 2.2 |
Western Africa | 2.7 | 3.3 | Poland | 2.8 | 2.1 |
Bangladesh | 3.9 | 3.3 | European Union | 1.6 | 1.9 |
Central Africa | 5.0 | 3.1 | Non-EU Europe | 2.7 | 1.9 |
Southern Asia | 3.6 | 3.0 | United Kingdom | 1.6 | 1.8 |
Eastern Africa | 2.3 | 2.6 | Southern Africa | 1.4 | 1.8 |
Middle East | 3.1 | 2.6 | Central America | 1.7 | 1.8 |
Sri Lanka | 3.5 | 2.6 | South America | 2.3 | 1.8 |
Oceania (excl. Australia) | 2.0 | 2.6 | North America | 1.7 | 1.7 |
India | 2.2 | 2.4 | Eastern Asia | 1.1 | 1.5 |
Caribbean | 2.8 | 2.3 | South East Asia | 1.5 | 1.5 |
Australasia | 1.2 | 1.3 |
Function |
---|
Chief Executive, Chairman, Non-executive directors |
Human Resources (Personnel, recruitment) |
Media and Communications |
Procurement |
Women’s and Children’s Management |
External advice (Management Consultant fees, Legal costs) |
State and local government taxes |
Insurance (buildings, equipment, clinical negligence) |
Estates and Facilities (buildings and grounds, maintenance) |
Finance, annual accounts, payroll, debt recovery, etc. |
Information Technology and supporting software |
Information Management, monthly reports, etc. |
Medical Records (non-computerized) |
Strategy and Planning |
Portering |
Patient transport |
Pathology (blood biochemistry, microbiology, etc.) |
Radiology |
Medical Instrumentation |
Intensive Care |
Housekeeping (cleaning, etc.) |
Health and Safety |
Infection Control |
Medical Illustration |
Library |
Capital costs via depreciation of buildings and equipment |
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Jones, R.P. Capacity Planning (Capital, Staff and Costs) of Inpatient Maternity Services: Pitfalls for the Unwary. Int. J. Environ. Res. Public Health 2025, 22, 87. https://doi.org/10.3390/ijerph22010087
Jones RP. Capacity Planning (Capital, Staff and Costs) of Inpatient Maternity Services: Pitfalls for the Unwary. International Journal of Environmental Research and Public Health. 2025; 22(1):87. https://doi.org/10.3390/ijerph22010087
Chicago/Turabian StyleJones, Rodney P. 2025. "Capacity Planning (Capital, Staff and Costs) of Inpatient Maternity Services: Pitfalls for the Unwary" International Journal of Environmental Research and Public Health 22, no. 1: 87. https://doi.org/10.3390/ijerph22010087
APA StyleJones, R. P. (2025). Capacity Planning (Capital, Staff and Costs) of Inpatient Maternity Services: Pitfalls for the Unwary. International Journal of Environmental Research and Public Health, 22(1), 87. https://doi.org/10.3390/ijerph22010087