The analysis presented mainly covers the period of 1999-2000 as the latest complete birth cohort, as the 2000-01 provisional data have significant deficiencies. It must be noted that for much of the data described for small units, especially <400 deliveries, they are too small to be regarded as statistically significant, especially with changes over time, and much of the data refers to singleton deliveries only due to the method of collection and ease of analysis. The average Scotland-wide twinning rate for 1999-2000 was 1.36% with a range of 0.44% (CGH) to 1.82% (AMH).
Population
In Appendix 4 of the
Framework document, an attempt was made to estimate the future number of births in Scotland and by NHS Board. The total birth rate has been declining from 67,000 births in 1995 to 55,147 in 1999 to 53,061 in 2000, with an Information Services Division (ISD) provisional 2001 figure of 51,642. The Registrar General for Scotland reported that actually 52,527 births were recorded in Scotland in 2001, the lowest number ever recorded and a 22% fall within the last 10 years (Registrar General for Scotland, Scotland's Population 2001). Birth rates in Scotland are lower than any other country in the United Kingdom and this projection is set to continue: the rates are similar to other European countries, some of which have lower birth rates than Scotland (Spain, Italy, Germany, Austria and Greece).
This trend is affected by the number of women of reproductive age (15-44 years), which is expected to fall from 109,000 in 1998 to 93,000 in 2016, and also on the age-specific fertility rates. These rates have been declining in Scotland since the baby boom peak in the 1960s, is consistent with that of most European countries and is expected to continue. It has declined in all age groups with the peak of child bearing age becoming older: the peak age of fertility in the 1960s was approximately 24 years of age compared to 30 years of age now. The mean age of first pregnancy is now later (26 years in provisional 2001 data) and the completed family size has fallen from 2.63 in 1934 to 1.95 in 1955 and an estimated 1.75 in 1999. Most women have completed their child bearing by 45 years of age and the period between first and last pregnancies has reduced.
There is a debate about the present plateauing of fertility rates in 20 year old women with some statisticians predicting reversion to a more normal curve (A Framework for Maternity Services in Scotland, 2001). It is impossible to predict future fertility rates with certainty. The Government Actuaries assume that completed family size will continue to fall off until the 1975 birth cohort, and then eventually level out. They also developed projections of birth numbers utilising the present period fertility rate assuming 1.75, in addition calculated rates for 1.6 and 1.4 family size. These projections have then been applied to the projected population of reproductive age women. Using the assumptions listed, the estimated number of births in Scotland per year until 2010 are shown in Table 2.1.
Table 2.1: Estimated Total Number of Births in Scotland Utilising Different Fertility Rate Assumptions 2000-2010 in Scotland in Thousands
Fertility Assumption | 2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 |
Published GRO Projection | 57 | 57 | 56 | 56 | 55 | 55 | 55 | 55 | 55 | 55 | 55 |
Revised GRO Projection | | 55 | 52 | 52 | 52 | 51 | 51 | 51 | 50 | 50 | 50 |
Age Specific Fertility Rates 1999 | 54 | 53 | 52 | 51 | 50 | 50 | 49 | 49 | 48 | 48 | 48 |
Completed Family Size 1.6 | 55 | 55 | 54 | 53 | 53 | 52 | 52 | 51 | 51 | 51 | 51 |
Completed Family Size 1.4 | 52 | 51 | 49 | 48 | 47 | 40 | 45 | 45 | 45 | 44 | 44 |
Source: ISD 2002
The
Framework also projected births by individual NHS Boards on the above assumptions, and this is shown in Tables 9, 10 and 11 of Appendix 4 of the
Framework. Although it is at an early stage, the best-fit projection appears to be the 1999 Age Specific Fertility Rates predicting 48,000 births in Scotland by 2010.
Birth Mapping
An extensive birth mapping exercise was undertaken by ISD and GRO. This mapped the postcode of residence of women when they gave birth and related this to the actual unit of delivery. Surprisingly, this showed that in general terms, women delivered in the maternity facility within their local NHS Board area or closest specialist centre (Level IIc or III). Obviously exceptions were noted in terms of maternal choice or referral relating to reasons of specific and complex fetal and maternal morbidities.
Live and Still Birth Deliveries by Maternity Units in Scotland
The different maternity units in Scotland at March 2002 by NHS Board Area, Levels of Intrapartum Care and Geographic Location are shown in Table A.1 (
Annex B ). A more extensive analysis of the number of deliveries by hospital and NHS Board is shown in
Table A.2 identifying population estimates, recent maternity numbers, home deliveries and the levels of intrapartum and neonatal care as identified by the
Framework. The decline in birth rate is generally reflected in all NHS Board areas, the exception being Borders and Lanarkshire.
Throughout Scotland there currently exists an informal network of different levels of provision of maternity care reflecting an evolved, tiered and geographical approach encompassing morbidity, case mix and rurality. Allocation of the units to the different levels of care is at March 2000 (
Table A.2) but subsequently
some changes in configuration and birth numbers have already occurred throughout Scotland.
Level III
In 2002 there were
4 regional centres of Level III consultant-led specialist maternal-fetal units, which delivered 35.3% of all deliveries and these consist of:
North | Aberdeen Maternity Hospital, Aberdeen |
South East | Simpson Memorial Maternity Pavilion, Edinburgh, now Simpson Centre for Reproductive Health |
West | Princess Royal Maternity Hospital and Queen Mother's Hospital in Glasgow |
Level II
There are
13 Level IIc consultant-led maternity units, which delivered 50.3% of all births in Scotland, and these units deliver approximately 1-3,000 babies per year, although there are some large units deliverying approximately 5,000 babies, but these are not specialist maternal fetal tertiary centres. There is a real variation in birth numbers and provision in the different units and
some of these have changed in recent rationalisation:
North | Raigmore Hospital, Highland |
South East | Ninewells Hospital and Perth Royal Infirmary, Tayside Forth Park Maternity Hospital, Fife St John's Hospital, Lothian |
West | Southern General Hospital, Greater Glasgow Royal Alexandra Hospital and Inverclyde Royal Hospital, Argyll and Clyde Stirling Royal Infirmary, Falkirk Maternity Hospital, Forth Valley Wishaw General Hospital, Lanarkshire Ayrshire Central Hospital, Ayrshire and Arran Cresswell Maternity Hospital, Dumfries and Galloway |
There are
4 Level IIb consultant-led maternity units with onsite neonatal facilities with less than 1,000 deliveries and they delivered 5.4% of all births. These are:
North | Western Isles Hospital, Western Isles Dr Gray's Hospital, Grampian |
South East | Borders General Hospital, Borders |
West | Vale of Leven Hospital, Argyll and Clyde |
There is only
one Level IIa consultant-led maternity unit without onsite neonatal facilities with less than 1,000 deliveries, this being Caithness General Hospital in Highland in the north region.
The location of the Level III and IIc maternity units reflects the urban centralisation of Scotland's population, while the relatively large numbers of IIa, Ic and Ib facilities highlights the dispersed remote and rural population of Scotland responding to local needs. While the 4 Level III centres apparently appropriately deliver the majority of the complex maternal-fetal case mix, it should be noted that all specialist facilities deliver a variety of care options for low risk women, which can depend on maternal choice and geographical factors. The 16 units designated as Levels III and IIc delivered 86.2% of all births, while 51.2% of all births took place in the 6 Scottish maternity units delivering more than 3,000 deliveries per year.
Level I
There are
5 Level Ic community maternity units adjacent to a non-obstetric District General Hospital (DGH) and these are:
North | Gilbert Bain, Shetland Balfour Hospital, Shetland Belford Hospital, Highland |
West | Dunoon & District GH and Lorne & Islands DGH, Argyll and Clyde |
There are now
18 Level Ib standalone midwifery units and these are as follows:
North | Daliburgh Hospital, Western Isles
Insch & District War Memorial Hospital, Jubilee Hospital, Kincardine O'Neil War Memorial Hospital, Chalmers Hospital, Fraserburgh Hospital and Peterhead Hospitals, Grampian
Portree Hospital, MacKinnon Memorial Hospital, Highland |
South East | Arbroath Infirmary, Montrose Royal Infirmary, Tayside |
West | Campbeltown Hospital, Victoria Hospital, Mid Argyll Hospital, Islay Hospital, all Argyll and Clyde Isle of Arran War Memorial Hospital, Davidson Cottage Hospital, Ayrshire and Arran Dalrymple Hospital, Dumfries and Galloway |
Level Ia refers to delivery in the home setting which presently accounts for <1% of all deliveries in Scotland and there is enormous regional variation.
Deprivation
The number and percentage of singleton deliveries, by hospital and deprivation quintile, are shown in
Table A.3. These are derived from the 1991 census on postcode sectors and the quintiles are based on total populations. This shows a close relationship of approximately 20% for the delivery population attributable to each quintile. While there is no real variation in deprivation quintile by maternity Scotland-wide, there is a huge variation by hospital unit, closely reflecting the east-west divide and this highlights obstetric and neonatal case mix, morbidity and co-morbidities and is evident in obstetric and perinatal outcome (Confidential Enquiries into Maternal Deaths, CEMD 2001).
Maternal Age
Maternal age by admission to hospital is shown in
Table A.4. This reveals that teenage pregnancies accounted for 8.9% of all pregnancies with the highest rates in IRH (12.8%) and ACMH (11.5%) and the lowest in PRI (7.1%), QMH (7.1%) and AMH (6.7%): the vast majority of teenage pregnancies were delivered in consultant-led units.
The age group of 20-34 year old mothers accounted for 76.3% of all deliveries with a surprisingly consistent spread throughout all maternity units. Women aged 40 years or above accounted for 2.1% of all pregnancies, with high rates noted in QMH and SMMP. Almost all elderly primigravidae were delivered in larger consultant-led units reflecting the associated morbidity.
The mean age of mothers at first births continues to rise and the 2001 provisional data shows the average as 26 years of age. The percentage of mothers giving birth aged >35 years above has doubled to 16.2% in the last decade, whereas the percentage of mothers < 19 years has fallen to 7.1%. Less deprived areas are associated with an older age at birth whereas the reverse is seen in highly deprived areas, once again reflecting higher morbidities and poor maternal-fetal outcome in deprived areas.
Parity
The range of parities is similar in CMUs and consultant-led units (
Table A.5). In Scotland 46.1% of deliveries were primigravidae, 47.5% were para 1-3 and 6.3% were greater than para 3. There is evidence to suggest that multi-parity (>3) or grand multi-parity is declining and that grand multiparous births are delivered in consultant-led units, again reflecting the higher associated risk.
Induction
There is a real difficulty and variation in the coding and recording of induction, with an apparent inconsistency in the identification and differentiation of induction, repeat induction and augmentation of labour. Therefore any interpretation must be made with caution (
Table A.6). The overall Scottish average induction rate is 27.6%: consultant-led unit average induction rate is 29.2% with wide variation of 42.4% (SRI), 46.0% (GRMH) and 37.8% (WIH) compared to SMMP (23.6%), FMH and BMH showing approximate rates of 23.5%. The overall CMU induction rate is 2.9% with significant variation of 33.7% (FH) and 14.5% (GBH) to most units with no inductions noted. There is generally no induction in CMUs, and the data highlights an absence of a consistent approach to induction and augmentation of labour throughout the consultant-led service in Scotland.
Mode of Delivery
The mode of delivery by hospital is identified in
Table A.7a and
Table A.7 b and should be interpreted with caution, since some of the units have small numbers. The statistics do not identify either the severity of case mix and morbidity or the transfer rates of women, who were booked for low risk care, and subsequently transferred to other maternity units.
In Scotland, spontaneous vertex deliveries (SVD) account for 66.3% of all deliveries. With the exception of Balfour (BH) and Gilbert Bain (GBMH), which are CMUs with facilities for operative delivery, the CMU SVD rate was approaching 100%, with a few assisted deliveries recorded. The variation between consultant units is difficult to explain solely on differential case mix.
The overall rate of intervention in births is 33.7% (ie non SVDs) with a wide range of 42.6% (RAH), 43.4% (AMH) to 25.4% (LH) and 26.3% (CMH). The rate of vaginal breech delivery (VBD) shows a steadily decreasing rate to currently only 0.6% of all deliveries, as many units now opt for elective caesarean section following a world-wide evidence based trend, possibly associated with the ineffectiveness and low use of external cephalic version.
The rates of assisted vaginal delivery (forceps and ventouse combined) has stabilised to an overall average of 12.4%, with significant variation between units in the ratio between forceps and Ventouse delivery reflecting clinical preference. The range of assisted vaginal delivery varies from approximately 17% (BGH, QMH, NHs and AMH) to 6.7% (LH) and 5% (CMH).
The rise of caesarean section rates in Scotland reflects that observed in westernised maternity care (Expert Advisory Group on Caesarean Section in Scotland 2001), with the total Scottish caesarean section rate being 20.7% in 1999-2000 and the provisional 2001 rate being reported as 21.9% (ISD, Scottish Hospital Statistics 2002). There is a marked variation by unit, which cannot be explained wholly by case mix or morbidity from 14.9% (IRH) and 15.4% (FMH) to 24.4% (AMH), 25.6% (RAH) and 26.3% (QMH). The emergency to elective caesarean range is 13.6% to 7.4% overall, with again wide variations between units. Projection of the number of caesarean sections, using the 1999 Age Specific Fertility Rates applied to the GRO reproductive age population, while utilising the present indications for caesarean section, suggests that this trend will indeed continue to rise (Table 2.2 below):
Table 2.2:Predicted Total Caesarean Section Rate in % by Years
2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 |
20.2 | 20.7 | 21.2 | 21.7 | 22.1 | 22.5 | 22.9 | 23.3 | 23.7 | 24.0 | 24.4 |
Source:
ISD 2002
It is noted that the main reasons for caesarean section include failure to progress, fetal distress, repeat caesarean section, breech presentation and increasingly maternal choice in the absence of any clinical indications. In mothers having a first baby > 35 years of age, caesarean sections occur in 39.8% of all cases. The overall average caesarean section rate for twin pregnancies is currently between 50% and 53%. The Expert Advisory Group on Caesarean Section recommended evidence based practice for undertaking caesarean section, which should all be prospectively audited.
Episiotomy and tears
There is huge variation in the incidence, coding and recording in relation to episiotomy and tears in vaginal deliveries and interpretation requires extreme caution. Of the 42,302 deliveries for which data on episiotomy status has been recorded (60% of total deliveries), 52% of these had no episiotomy, while 17.5% of vaginal births had an episiotomy, thus highlighting the data deficiencies. The consultant-led units had an average rate of 25.2% (range 8.5% to 38.8%), while the overall CMU episiotomy rate was 5.2% (range 0-19%). Of the 16,959 vaginal deliveries recorded for tears 16.5% were first degree tears or lacerations, 10.9% second degree tears and only 0.4% third and fourth degree tears combined. No third or fourth degree tears were recorded in CMUs within these returns and no transfers were required for specialist repair by a specialist centre.
Gestation and birth weight
The details on the number of deliveries and percentages by hospital gestation and birth weight are identified in
Tables A.8 and
A.9 . Most deliveries in Scotland are at term with 93% being recorded as over 37 weeks' gestation in the period of 1999-2000. The overall prematurity rate has stabilised at approximately 6.9% over the last 5 years: 5.7% were 32-36 weeks, 0.8% were 28-31 weeks and only 0.4% were under 28 weeks. Similarly 90.7% of births were in the birthweight category of 2500-4499gms while 1.2% were under 1500gms, 6.2% between 1500-2499, and 1.9% were above 4500gms. It would appear that most low birthweight/very low birthweight and premature/extremely premature babies are generally being delivered in the appropriate consultant-led Level IIc and III centres, with adequate maternal and neonatal facilities nearby.
Admissions and length of stay
The number and percentage of length of stay for ante-natal admissions are recorded in
Table A.10 - this does not include "delivery admissions", identify multiple admissions for the same pregnancy or state the reason for admission during the ante-natal period. 96.4% of all admissions are less than 4 days and there is very little variation between units. The pattern of ante-natal admissions and discharges between maternity units is generally consistent with the regional incremental level of ante-natal care approach reflecting morbidity.
Table A.11 illustrates deliveries transferred from another hospital around the time of labour, which generally illustrates the tiered level approach: 2.4% (1,275 deliveries) were admitted to a different maternity unit in the same provider Trust, while only 1.1% (570) were admitted from a different Trust provider unit to a more specialist unit.
Postnatal length of stay (
Table A.12) has fallen over the last 10 years. In the 1999-2000 returns, 75.7% of deliveries were discharged under 4 days, 19.7% within 4-6 days and only 4.6% last over 7 days: the provisional postnatal average length of stay for 2000-01 is reported to be 3.2 days, but covers all case mix. There is a wide variation between both CMUs and consultant-led units reflecting increased postnatal stay due to rurality and case mix: increased postnatal stay is correlated with caesarean section, operative vaginal delivery, maternal co-morbidities and neonatal complications. The trend of early postnatal discharge (< 24 hours), is significantly increasing with uncomplicated deliveries and even operative or more complex births are either being discharged earlier into the community or being transferred to a lower level of maternity care facility
Maternal co-morbidities
Adverse pregnancy outcome for mother and fetus is strongly linked to social deprivation and complications such as preterm labour, intrauterine growth restriction, low levels of breast feeding and high levels of neonatal morbidity. Women who experience such pregnancy complications are at substantially higher risk of developing cardiovascular disease in later life. In addition babies born to mothers with pre eclampsia are also at increased risk of premature delivery and being born very small. Babies which survive are maybe at increased risk of high blood pressure and diabetes in adult life. In order to minimise this cardiovascular risk much current research is focusing on the potential of maternal and fetal therapy to effectively manipulate growth of the fetus and placenta.
The most recent edition of
"Why Mothers Die" (Confidential Enquiry into Maternal Deaths, 2001) highlights the relationship between social exclusion and the likelihood of maternal death. Socio-economic deprivation is associated with less effective health service use and poor health status (Williams, 1990; Townsend & Davidson 1982) and other factors which adversely influence pregnancy outcomes, such as drug abuse, also correlate with social deprivation (Hepburn & Elliott, 1997). Underlying factors which impact on maternal and child health are high levels of smoking, obesity reflecting poor diet and sedentary lifestyle. The adverse pregnancy outcome associated with socio-economic deprivation is compounded by the high psychological cost to women of living in poverty, this impacts on the health and wellbeing of the whole family.
Strong evidence indicates that the course of events experienced by pregnant women and their infants and young children influences development, well-being and health throughout later life. Healthy development is influenced by a variety of familial, socioeconomic and environmental factors, and by nutritional status, chronic disease and disability. All populations have critical periods of increased vulnerability during the development process that are predictive of long term health; and additionally certain populations (for example, the offspring of parents with mental illness) are at high risk throughout development. It is during these developmental periods and at times of transition that an unhealthy developmental pathway or disorder can be magnified and result in lifelong adverse consequences.
Disorders occurring during the early stages of the lifecycle have the potential for severe impact on individuals and families across lifetimes and generations. Examples include infertility and difficulties in early pregnancy that lead to pre-eclampsia (in 5-7% of all pregnancies) or preterm birth (6-10% of pregnancies, accounting for more than 75% of neonatal mortality and morbidity, and considerable later disability and neurological handicap). Child and youth physical and mental health problems carry a heavy burden for the affected individuals and their families. For example, at least 20% of children or adolescents have clinically important emotional or behavioural problems or chronic medical illness.
Neonatal provision
Optimal neonatal care is provided by an appropriately trained team, including midwives, neonatal nurses and medical paediatricians. The neonatal workload in all maternity units includes the routine care of healthy newborn infants by appropriately trained staff within an appropriate environment, including the establishment of breast or artificial feeding. A 24 hour service for neonatal resuscitation is required for all confinements, while acute care is focused on emergency and anticipated resuscitation, attendance at high risk deliveries and the management of babies requiring special or intensive care. Both the initial acquisition of competencies and the subsequent updating and retention of skills requires to be addressed. Each unit should clearly state the level of neonatal care offered to allow mothers informed choice of the type of facility and level of care, that they wish for their babies.
In CMUs, complications arising in labour will require on-site resuscitation and management by midwives, or GPs where appropriate, and on occasions transfer by a midwife and paramedic to an appropriate consultant-led facility. CMUs can no longer rely on emergency back-up of neonatal and obstetric flying squads. Therefore all units providing any care to neonates must be capable of providing resuscitation and short-term support for the sick infant, whilst activating the neonatal transport system. With the increasing trend of early discharge of mothers and infants from maternity units, it is impossible to identify all neonatal morbidity within the unit setting, as conditions may only emerge once the transitional period of neonatal adjustment has been completed.
Optimal neonatal care, outwith the home or CMU, is best provided within an hospital setting with integration of maternity and neonatal services, supported by medical paediatrics, specialist services and a comprehensive range of support services. The configuration of present neonatal provision in Scottish consultant-led obstetric units is shown in
Table 2.3. In these consultant-led obstetric units approximately 20%-25% of deliveries are attended by a member of the neonatal team and subsequently 10%-15% are admitted to a special or intensive care cot.
The staffing requirements will vary depending on the unit case mix and the level of neonatal care provided. In Scotland neonatal care is experiencing a deficiency of appropriately trained neonatal nurses and midwives due to difficulties with recruitment and retention. The reduction in junior doctors' numbers and hours has had a significant effect in maintaining neonatal and paediatric rotas.
Consultant-led obstetric units, isolated or at a distance from a District General Hospital with a paediatric service, present difficulties in paediatric staffing and paediatric support. In smaller units with paediatric in-patient beds, resident staff may be responsible for both neonatal and general paediatric care: these units may require the support of neonatal nurse practitioners in order to provide appropriate support to labour wards and Special Care Baby Units. The paediatric staff will vary according to the unit: in consultant-led services with a Special Care Baby Unit, the care of infants must be supervised by an appropriately trained consultant with 24 hour resident experienced junior staff.
With the increasing recognition of antenatal morbidity and congenital malformations by detailed fetal scanning, antenatal discussions between perinatal specialists and neonatologists will facilitate the management and delivery of these high risk infants. The immediate postnatal management of some high risk infants will only be available in a few specialist sites in Scotland: planned pre-natal intrauterine transfer remains the safest form of transfer in most cases, augmented by a neonatal transport system.
Regional planning of maternity services will lead to a comprehensive review of all levels of neonatal provision, both locally and regionally and should address the rationalisation of special and intensive care sites in Scotland.
Table 2.3: Neonatal provision in consultant-led obstetric units:Scotland September 2002
Regions by Hospital | City/Town | Approx number of deliveries | General Paeds on site | Level of neonatal care | Neonatal Surgery | Out of hours cover (trainee) |
NORTH | | | | | | |
Aberdeen Mat | Aberdeen | 4,500 | Y | NICU | Yes | Dedicated |
Raigmore | Inverness | 1,800 | Y | NICU | No | Shared duties |
Western Isles Hospital | Stornoway | 180 | Y | Normal Care | No | Con Community Paediatrician |
Caithness General | Wick | 150 | N | Normal Care | No | GP |
Dr Grays | Elgin | 800 | Y | SCBU | No | Shared duties SHO1 |
SOUTH EAST | | | | | | |
Simpson | Edinburgh | 6,250 | N | NICU | No | Dedicated |
Borders General | Melrose | 1,000 | Y | SCBU | No | Shared duties |
St John's | Livingston | 2,500 | Y | SCBU | No | Shared duties |
Forth Park | Kirkcaldy | 3,000 | N | NICU | No | Shared (split site) duties |
Ninewells | Dundee | 3,000 | Y | NICU | No | Dedicated |
Perth Royal | Perth | 1,200 | Y | Normal Care | No | Shared duties |
WEST | | | | | | |
Princess Royal Mat | Glasgow | 4,500 | N | NICU | No - close | Dedicated |
Queen Mothers | Glasgow | 3,500 | Y | NICU | Yes | Dedicated |
Southern General | Glasgow | 3,000 | N | NICU | No - close | Dedicated No paed inpatients on site |
Royal Alexandra | Paisley | 2,000 | Y | NICU | No | Shared duties |
Inverclyde | Greenock | 1,000 | Y | SCBU | No | Shared duties |
Vale of Leven | Alexandria | 900 | N | SCBU | No | Dedicated No paed inpatients on site |
Ayrshire Central | Irvine | 3,500 | N | NICU | No | Dedicated and or Shared |
Cresswell now attached to D&GH | Dumfries | 1,200 | Y | SCBU | No | Shared duties |
Wishaw | Wishaw | 4,500 | Y | NICU | No | Dedicated |
Stirling Royal Falkirk Royal | Stirling Falkirk | 1,500 1,400 | Y N | NICU SCBU | No No | Shared duties Dedicated No paed inpatients on site |
TRANSPORT IN ACUTE MATERNITY SERVICES
Existing services
Ambulance transport is accessed in three main ways: the 999 system, direct telephone numbers used by GPs and hospital based clinicians, and by pre-book forms sent by mail or fax to the appropriate control centre. The 999 system will result in an emergency response: direct telephone contact by a GP or hospital clinician will have a varied response, emergency or urgent, dependent on the clinical condition of the patient. The pre-book form is used to arrange routine type journeys, most of which are conducted by the Non Emergency Service.
At the time of arranging ambulance transport, the control centre nearest the location of the patient is the point of contact for all of the above methods of access. Any ordering authority can contact the Air Desk, but the public do not have direct contact with this facility. The Air Desk is currently located in Aberdeen and co-ordinates all air ambulance activity across Scotland. The air fleet operates six aircraft, two rotary and four fixed wing. The two helicopters work from Inverness and Glasgow. The fixed wing planes work from Aberdeen, Kirkwall, Lerwick and Glasgow.
The provision of ambulance transport is currently facilitated from eight Operational Control centres serving the relevant NHS Board Areas. The following table shows the ambulance control centres and the NHS Board areas they serve.
Table 2.4 : Ambulance Control Centres
Ambulance Control Centre | NHS Board Areas |
Edinburgh | Lothian & Borders. |
Glasgow | Greater Glasgow. |
Paisley | Argyle & Clyde. |
Ayr | Ayrshire & Arran and Dumfries & Galloway. |
Aberdeen | Grampian, Orkney & Shetland. |
Inverness | Highlands & Western Isles. |
Motherwell | Lanarkshire. |
Dundee | Tayside, Forth Valley & Fife. |
Land based vehicles operate from 152 locations across Scotland and are staffed by a mixture of paramedics and technicians. The ability to have a paramedic in every frontline ambulance will vary across the country depending on the staff mix within the Division. The target is to have a paramedic in every frontline ambulance in 2005.
Many ambulance staff are concerned that they may not have the necessary skills and competencies to deal with home deliveries or obstetric emergencies. The existing basic training does not fully equip them with the range of competencies they may require in the event of an unplanned birth or an obstetric emergency. Consequently, many ambulance staff request back up or they move the woman to the nearest A&E Department, which may not have any on-site maternity support. The ability to maintain relevant skills is reduced as exposure to obstetric emergencies is low in comparison to other patient categories. This leads to a loss of skill and confidence in front line ambulance staff. Inter-hospital transfers account for a high proportion of maternity related ambulance work. Organisationally, inter-hospital transfers present concerns related to managing the resource to the location, maintaining ongoing business whilst a resource is being utilised for a protracted period of time, and the overall service time that transfers can take. Factored into this must be the time it takes for the ambulance team to return to base following the transfer.
Existing maternity workload
The provision of detailed statistical information related to maternity patients is not currently available, but it is possible to obtain data related to activity and journeys by way of location, type and number.
In the year 2001 to 2002, a total of 6339 calls were handled under the very broad heading of 'Maternity' and although Accident & Emergency resources managed all of these, a number of the journeys would have been planned. Table 2.5 highlights the number and nature of emergency calls, with the majority originating at home
Table 2.5: Emergency calls to SAS
Presenting Condition | Outside | Home | Business Premises | Inter-Hospital | Other | Total |
Gynae/Miscarriage | 13 | 398 | 49 | 11 | 2 | 473 |
Pregnancy/Childbirth | 68 | 2099 | 156 | 160 | 9 | 2493 |
Total | | | | | | 2966 |
Table 2.6: Urgent calls to SAS
Presenting Condition | Outside | Home | Business Premises | Inter-Hospital | Other | Total |
Gynae/Miscarriage | 1 | 359 | 34 | 148 | 5 | 547 |
Pregnancy/Childbirth | 14 | 1624 | 90 | 1035 | 63 | 2826 |
Total | | | | | | 3373 |
This data may not be all-inclusive, as it only identifies cases which are 'called in' as pregnancy specific.
Neonatal Transport
Following the Acute Services Review, Sir David Carter, the then Chief Medical Officer, commissioned Dr Phil Booth (consultant neonatologist, Aberdeen) to chair a Working Group to consider the Transport of Critically Ill and Injured Children in Scotland. The paediatric section of this report was submitted in 2000, which resulted in a centrally funded nationally co-ordinated dedicated paediatric transport and retrieval service: the Managed Clinical Network was commissioned by NSD and consists of two dedicated retrieval teams based in Edinburgh and Glasgow.
Due to the diversity and complexity of the provision of neonatal services in Scotland, the different needs of critically ill neonates and the significantly different manpower providers of the service compared to paediatric intensive care, a separate report on Neonatal Transport was commissioned.
This report was submitted to the Scottish Executive Health Department in March 2002, and the findings and recommendations were accepted. Interim funding was secured to maintain the service until April 2003. The Chairs of the 3 Regional Planning Groups have been asked to implement the recommendations of the report through the regional planning structure, to ensure that a comprehensive and integrated neonatal transport system is developed throughout Scotland, based on the recommendation of 3 Regional Transport Groupings. National Services Division are currently facilitating the development of interim arrangements on behalf of the regional planning groups. A comprehensive summary of the report is set out in
Annex G.
Future plans and configuration
In keeping with changing demographics and service requirements, the nature of Scottish Ambulance Service (SAS) provision has been reviewed. The review considered the role, function and location of all Operational Control centres. There is a planned restructuring of this element of the service and over the coming two years the number of centres will reduce from eight to three in the following configuration.
Table 2.7: Future centres for operational control
Ambulance Control Centre | Health Board Areas |
Edinburgh | Lothian & Borders Tayside, Forth Valley & Fife |
Paisley | Greater Glasgow Argyll & Clyde, Ayrshire & Arran Dumfries & Galloway, Lanarkshire |
Inverness | Highlands & Western Isles, Grampian, Orkney and Shetland |
These three centres will co-ordinate, manage and resource all accident and emergency activity throughout Scotland. These centres are to be referred as Emergency Medical Dispatch Centres (EMDC) and will operate a priority based dispatch system which will categorise all 999 calls dependant on individual patient needs. The non-emergency service will be delivered from 30 hospital sites, supported and co-ordinated centrally from a national planning processor in Dundee.
The Air Desk is also being moved to Dundee and will be called the Transport Co-ordination Centre. The Dundee EMDC will also provide a business recovery centre should any of the three main centres fail. There should be the facility for clinicians to make one call to arrange transport and this could be organised through the Transportation Co-ordination Centre (Air Desk). This would ensure that the most appropriate method of transport is identified and advice is given as to which mode best suits the journey type in relation to the condition of the patient, at which time issues relating to equipment, skills mix of crew and potential police escorts are discussed.
The introduction of Priority Based Despatch will help manage the emergency workload and has the potential to improve the availability of ambulances. However, this will vary by area, by time of day and by day of week.
It is important to ensure that the type of vehicle used best suits the transfer function. The vehicle fleet should be reviewed, but it would not be realistic to base fleet requirements only on obstetric or neonatal transfer. The Scottish Ambulance Service advises that it would be more practical to have a limited number of specialised vehicles to facilitate inter-hospital journeys.
The level of resource required to support any change in configuration of intrapartum care should consider the following points: