BackgroundChina has made impressive progress in improving maternal and child health nationally, although national progress might conceal inequality across regions within China. Mortality ratios in western counties remains high, and midwives in western areas are in extreme shortage as guarantors of maternal and child safety. This study aims to investigate the current situation for the midwifery service in western China and to explore the demand for midwifery human resources in the area using the Birthrate Plus workforce planning methodology. MethodsFirst, we did a cross-sectional survey in 28 hospitals in three western provinces—Yunnan (southwest China), Inner Mongolia (northern China), and Xinjiang (northwest China)—to investigate the status of the midwifery service and midwifery human resources using a tailored questionnaire. We selected two tertiary hospitals in each province, as well as eight secondary hospitals in Yunnan, six in Inner Mongolia, and 14 in Xinjiang, to reflect population sizes (according to the National Health and Family Planning statistical yearbook). Questionnaires were sent to midwifery managers in the 34 hospitals, and 28 returned the questionnaire (all six tertiary hospitals, seven secondary hospitals in Yunnan, five in Inner Mongolia, and ten in Xinjiang). Second, we analysed medical records from all women attending the midwifery departments of the 28 hospitals (n=18 520) who received midwifery services in 2017 and 2018, and the Birthrate Plus workforce planning methodology was used, with modifications, to calculate demand for midwives in each hospital. Women were divided into five categories according to the Birthrate Plus guidelines (of which categories I and II were natural deliveries with no need for intervention, and categories III–V required different levels of intervention). Two core elements were analysed: the percentage of maternity patients in each category and midwifery service time (time in the delivery suite, from admission in labour to leaving for the postnatal unit or operating room for caesarean section) in each category. Each hospital gave informed verbal consent. The study was approved by the Peking University institutional review board office. FindingsThe maximum and minimum annual delivery volumes per hospital were 12 048 and 192, respectively. The highest and lowest caesarean section rates were 59·00% (472 of 794) and 20·86% (907 of 4345), respectively, and the average caesarean section rate was 38·49% (SD 10·33). A total of 476 midwives in 28 hospitals were included. 94·34% (417 of 476) of the midwives had an initial educational level below a bachelor's degree, and 69·75% (332 of 476) had less than 10 years of work experience. Data from a total of 18 520 maternity patients from 28 hospitals were eligible for analysis. According to the Birthrate Plus results, 37·2% (6890 of 18 520) maternity patients were in category I/II (grouped together for comparison), 42·1% (7804 of 18 520) in category III, 18·1% (3343 of 18 520) in category IV, and 2·6% (483 of 18 520) in category V, and midwifery service times of each category were 6·79 h, 9·92 h, 9·89 h, and 11·93 h, respectively. The actual number of midwives in the majority of hospitals (67·86%, 19 of 28) exceeded the calculated demand, while that in 21·43% of hospitals (six of 28) was less than the calculated demand, and in 10·71% of hospitals (three of 28) the actual number of midwives was consistent with the calculated demand. InterpretationThe midwifery service varied between hospitals in western China. Given that inexperience or lack of education negatively affect the core competencies of midwives, it is likely that these factors affected the midwifery service that patients received. Efforts are needed to promote the construction of midwifery teams. Most maternity patients belonged to categories I–III, and gave birth naturally or with less need for interventions. However, women in categories IV and V, who represented a small proportion of the overall data set, experienced pregnancy complications or required more interventions than those in categories I–III, and thus tended to require longer midwifery hours. The surveyed hospitals varied in type (general hospitals, and maternity and child health hospitals) and level, and provided services for different numbers of each category of maternity patient, and thus the midwifery service time varied accordingly. For example, there were more maternity patients in categories IV and V in general hospitals than in maternal and child health hospitals, which suggests that more midwives may be required in general hospitals to care for the same number of maternity patients. Therefore, it is necessary to fully consider the service characteristics of hospitals when allocating midwifery human resources. Our findings suggest that Birthrate Plus workforce planning methodology can be used to accurately assess workload of midwives based on the status of the midwifery service in China. Its applicability as a midwifery demand assessment tool in western China should be explored further. FundingThis study was funded by the UN Children's Fund (Maternal and Child Health Management Information System).