A number of important changes within the workforce arena have implications for maternity services. The
Review of Specialist Registrar Training by Professor Calman in 1993, the New Deal for Junior Doctors in 1991, the European Working Time Directive and the difficulties encountered in recruitment and retention of staff, and the decline of general practitioners' involvement in intrapartum care, are amongst a range of developments resulting in workforce pressures. The Scottish Integrated Workforce Planning Group Report suggested that planning for the workforce must take account of models of care provision, and
Working for Health - the Workforce Development Action Plan (August 2002) confirmed the need to plan services and workforce together.
Future Practice: A Review of Scottish Medical Workforce concluded that increasing specialisation and restrictions on working time make traditional patterns of medical staffing untenable. Professor Temple concluded that "all current acute service configurations need to be reviewed to test the validity and viability to sustain a high quality 24 hour service …..". He suggests that more doctors, a change in professional practices and, critically, a redesign of the NHS is required.
Policy Context
Our National Health: a plan for action, a plan for change was published in December 2000. The Scottish Executive set out the plan for innovation and reform of the National Health Service in Scotland to achieve a stepwise change in the health of the Scottish people and in the quality, access and responsiveness of the healthcare system in Scotland. The then Minister of Health, Ms Susan Deacon, asked the Chief Nursing Officer to develop
A Framework for Maternity Services in Scotland based on a comprehensive consultation with the public and professionals throughout Scotland.
The Scottish Executive Health Department aims to work in partnership with individuals, communities, and service planners and providers to ensure that children across Scotland receive the best possible start in life - even before birth. Maternity services, therefore, have a fundamental role to play in providing women, their partners and their babies with the care and support they need at this important time. There is the need to ensure that women receive high quality maternity care before, during and after pregnancy. The
Framework sets out the philosophy and principles within a template to develop priorities in maternity care, challenging the National Health Service to meet the needs of women and their partners and empower professionals and public alike to rise to that challenge.
Remit of the Expert Group on Maternity Services (EGAMS)
The Group was asked to consider national, regional and local planning of maternity services, and promote innovative approaches to intrapartum care, consistent with the principles set out in the
Framework. This is expected to assist NHS Boards to plan and configure their acute maternity services.
The Group was also asked to review and summarise international approaches to intrapartum care and describe the present configuration of acute maternity services in Scotland. It was required to apply appropriate models of acute maternity care and delivery, consistent with the
Framework, to Scottish geography and demography to ensure a patient centred, safe service, available to patients as close to their home as possible. The Group was required to describe how to maximise patient choice whilst ensuring proper assessment and safe management of risk. In addition, the Group was asked to consider the development of a regional approach to the management of high risk obstetric care, based on the hub and spoke model set out in the Acute Services Review.
Two subgroups were established related to risk assessment and clinical competencies. From the onset both groups worked in collaboration, sharing the same philosophy and principles and receiving feedback and notes of respective meetings. Following the initial subgroup meetings, the groups combined to work more effectively and considered the types of maternity units according to the levels of intrapartum care and neonatal care identified in tables 20 and 21 of the
Framework (pages 7 and 11).
The full remit and membership of EGAMS and its subgroups is contained in
Annex A.
A Framework for Maternity Services in Scotland
This set out a vision and philosophy for maternity services that would provide women with a family centred, locally accessible, essentially midwife managed, comprehensive and clinically effective model of safe care, before, during and after childbirth, which reflects a multi-disciplinary integrated approach to care. Different levels of maternal and neonatal care were identified to be appropriate for care to meet the needs of Scotland's urban and rural communities. It also reiterated that pregnancies and childbirth were a normal physiological process, that women should be involved and consulted in the decision making process, that care should be safe and evidence based and risks discussed and agreed by all and be provided within the community setting when appropriate.
The attainment of a safe outcome for mother and baby was paramount.
Levels of intrapartum care by location and childbirth
Table 1.1: Levels of intrapartum care by location and childbirth
Level of care | Location of delivery | Lead carer | Clinical situation | Care need and delivery | Suggested No. of del |
Ia | Home (planned) | Midwife (GP) | Normal pregnancy and labour | Suitable home facility with back-up from the Scottish Ambulance Service (paramedics) and supporting advice from a linked maternity unit | |
Ib | Stand-alone community maternity unit | Midwife (GP) | Normal pregnancy and labour | Appropriately equipped midwifery unit for normal care and agreed transfer guidelines to a linked maternity unit | |
Ic | Community maternity unit adjacent to non-obstetric hospital | Midwife (GP) | Normal pregnancy and labour | As Ib above. Medical staff (surgeon/GP) appropriately trained to perform emergency caesarean section | |
Id | Community maternity unit adjacent to maternity unit | Midwife (GP) | Normal pregnancy and labour | As Ib above | |
IIa | Consultant-led maternity unit with no neonatal facility | Consultant Obstetrician(plus midwife) | Low risk pregnancy and labour | Maternity unit care with monitoring facilities and anaesthetic cover with no access to paediatric facilities on site | <1,000 |
IIb | Consultant-led maternity unit with on-site neonatal facility | Consultant Obstetrician (plus Midwife) | Low to medium risk pregnancy and labour | Maternity unit care with monitoring facilities, access to anaesthetic and paediatric cover, but transferring out as required to special care baby unit or neonatal intensive care in a larger maternity unit | <1,000 |
IIc | Consultant-led maternity unit | Consultant Obstetrician(plus Midwife) | Low and most high risk pregnancies and labour | Full maternity unit and support services with easy access to special care baby unit/neonatal intensive care and access to adult high dependency care and adult intensive care | 1,000-3,000 or more |
III | Consultant-led specialist maternity unit | Consultant Specialist in Maternal Fetal Medicine(Midwives /others) | Complex and high risk pregnancies and labour | As for level IIc, but with on-site neonatal intensive care and access to neonatal surgery and adult intensive care | >3,000 |
A summary of the main principles and key points outlined in the
Framework for Maternity Services is set out below.
Information and communication (Principles 23-27)
There must be an appropriate and comprehensive Maternity Services Database to inform current practice and future development, both locally and nationally. This should be underpinned by a comprehensive standardised national multi-professional woman-held maternity record, covering all aspects of maternity care. Public and professional consultation should be fundamental to service design and provision. Women of reproductive age should have easy access to evidence-based information as well as to all services relating to any aspect of reproductive healthcare. A system of advocacy should be developed. The use of telemedicine technology should be developed, especially in remote and rural and isolated communities, both for communication, service provision and continuing and further education. All professionals must be adequately trained to ensure high quality verbal and written communication between women, their families and all carers involved in all aspects of maternity care to ensure team working and a sensitive approach when complex issues arise.
Service organisation and provision (Principles 18-21)
Maternity care should be organised to provide a comprehensive, clinically effective and safe, flexible, integrated, multidisciplinary, seamless and accessible service tailored to meet the needs of women and their families, within a safe and secure environment. Women with special needs require specific and targeted provision. Health Boards must develop Maternity Services Strategies and Local Implementation Schemes within a local and regional context, in the light of national guidance. They must ensure professional and public consultation and involvement, while developing a managerial framework covering all levels and locations of provision. Care should be based on local guidelines. Regard should be given to alternative models of care and continuity of care and carer, which also considers the needs of the workforce in terms of leadership, skills, competencies, training, education, clinical standards, accountability and audit. The specific issues of recruitment and retention and remoteness and rurality need to be considered. The Clinical Standards Board for Scotland will develop a range of maternity standards. Arrangements for the transfer of in-utero or postnatal mother and babies to a linked secondary or tertiary unit should be developed ensuring that the decision-making process is appropriately made by experienced professionals supported by agreed local guidelines.
Risk assessment and management (Principle 22)
All health professionals must have a clear understanding of risk assessment and management to improve the quality of care, and this should be carried out in partnership with women, especially to inform their Birth Plan. NHS Trusts should develop Risk Assessment and Management Programmes for both clinical and non-clinical risk, including review and audit, and they should develop guidelines for the management of complications arising in pregnancy.
Pre-conception and early pregnancy (Principles 1-3)
To ensure that all women have maximal health status before, during and after pregnancy service providers must provide a comprehensive health promotion and health education programme, and ensure informed access to appropriate care is available. A service should be developed specifically for both pre-conception and early pregnancy problems.
Pregnancy in the antenatal period (Principles 4-8)
Maternity services should provide a women and family centred, locally accessible, comprehensive, safe and clinically effective care with communication and integration between different levels and locations of care. The majority of antenatal care is low risk and should be midwife managed, with where relevant GP involvement and the appropriate incremental care being provided by secondary and tertiary care providers. This should be developed considering the RCOG Three Level Tiered Model based on risk assessment and locally developed guidelines. Women's needs should be holistically assessed with appropriate and easy access to all care providers. There should be a comprehensive antenatal diagnostic and screening service. The parent education and health promotion programme should be comprehensive and partners should be encouraged to take an active role throughout pregnancy.
Childbirth (Principles 9-11)
Women have the right to be involved in the decision-making process when choosing how and where to give birth. This should be supported by comprehensive, high quality information and evidence-based clinical advice regarding all aspects of obstetric, neonatal and anaesthetic care, including risk and geographical factors. Maternity services, including all aspects of obstetric, neonatal, anaesthetic and other specialist services, should provide a fully integrated service, responsive to the needs of the mother and baby. When planning the locations for childbirth, the Royal College of Obstetricians and Gynaecologists (RCOG) Three Level Tiered Model approach to incremental care should be considered as previously identified (
see Table 1.1).
All locations of delivery should be developed within a local and regional geographic network of care with guidelines for escalating levels of intrapartum care and transfer. There should be agreed entry and exit criteria for intrapartum care within all locations. One to one midwifery care should be given to all women in labour and childbirth to ensure individual attention and support, preferably with continuity of carer. The full range of midwifery and obstetric care should be available in all secondary and tertiary centres. Planned home births should have a comprehensive and agreed Individual Action Plan. Maternity services staff should be given appropriate support, training and education to maintain the appropriate skills and competencies to ensure that appropriate care may be given within the different levels and locations of intrapartum care. Leadership is essential in labour wards, which should have identified midwifery, obstetric, paediatric and anaesthetic leads and there should be arrangements for direct consultant involvement in the intrapartum care of high risk cases. A multidisciplinary Labour Ward Forum should be in place, which will include ongoing service monitoring review and auditing as well as multidisciplinary training.
Postnatal and parenthood (Principles 12-17)
Maternity services should provide comprehensive, integrated, multi-professional and flexible postnatal care and support the family to facilitate successful transition to motherhood and parenthood, having regard to parental informed choice and continuity of care. The prevention and detection of ill health are crucial, especially mental health, and appropriate management of any morbidity should be provided. Acute and primary care providers should develop a Four Level Tiered Model approach to neonatal care, developed by the British Association of Paediatric Medicine (BAPM) and adapted in Table 21 of the
Framework (see Table 1.2 below) ensuring that appropriate need is met, based on locally developed guidelines and transition between levels of care. Multi-professional support must be planned and provided on discharge. Services must inform and then support mothers in their choice of infant feeding, while promoting, supporting and sustaining breastfeeding as the preferred method. A debriefing of their experiences within this pregnancy should be offered.
Levels of neonatal care by location
Table 1.2: Levels of neonatal care by location
Level of care | BAPM category | Location | Lead carer | Support carer | Care |
I | Normal Care | Home, GP/Midwife Unit, Maternity Unit I-III | Mother + wider family | Midwife, Neonatal Nurse, Paediatrician | Advice and supervision, birth examination, vitamin K administration, discharge examination, screening programme, parental support and education |
II | Special Care | Maternity Unit I-III, Postnatal Ward, Transitional Ward, Special Care Baby Unit | Midwife, Specialist neonatal nurse, Mother | Paediatrician, Midwife, Specialist Neonatal Nurse | Care and treatment exceeding normal care includes Level I care |
III | Level 2 High Dependency Intensive Care | Maternity Unit II-III, Special Care Baby Unit, Neonatal Intensive Care | Paediatrician/ Neonatologist | Specialist Neonatal Nurse | Continuous skilled supervision but not as intensive as Level IV, parenteral nutrition, respiratory support, intra arterial monitoring, includes Level I care |
IV | Level 1 Maximal Intensive Care | Maternity Unit II-III, Neonatal Intensive Care | Neonatologist | Specialist Neonatal Nurse, Other consultant specialities | Continuous highly skilled supervision, assisted ventilation, circulatory support, peritoneal dialysis, post-op care, intensive parental support, Includes Level 1 Care |
SUMMARY AND WAY FORWARD
There is a consensus of opinion amongst the planners and providers of maternity care throughout Scotland that, given the constraints raised in the previous sections, the present configuration and levels of intrapartum and neonatal care are no longer sustainable in the short, medium and long term.
This has arisen due to changes in the population and demographic features. Scotland has a centralised population density with some rural dispersion together with a reducing population, a falling birth rate, a reduction in family size and women having children later, thus changing the volume and complexity of intrapartum care. Maternity needs have changed as there are more complex maternal morbidities, complex and operative delivery procedures are increasing and advanced neonatal care means that ill, premature and low birthweight babies are being looked after more successfully. All maternity care professions are experiencing difficulty in recruitment and retention. Increasing demands of clinical governance and quality of care mean that it is difficult to provide an appropriately trained and competent professional workforce to provide quality of care in all the present intrapartum locations. In terms of the medical workforce, there are difficulties in future compliance with 48 hours European Working Directive. The constraints on junior doctors' working hours and implementation of the Calman recommendations on medical training, coupled with difficulties experienced in recruitment and retention and increasing demands of clinical governance and quality of care, make it increasingly difficult to provide an appropriately trained workforce to provide quality care in all the present intrapartum locations.
Progress to fully implement the
Framework for Maternity Services in the light of recent events has not resolved the difficulties of providing safe, comprehensive and effective intrapartum care throughout Scotland. It is timely, that professionals and consumers within maternity services in Scotland have been given the opportunity to review the available evidence and advise on a way forward for intrapartum care, which will take account of the drivers for change and ensure delivery of an enhanced quality service. The findings of the Group will be addressed in the following sections of this report.