This section provides some background setting Scottish maternity services within the international context, but is not exclusive or exhaustive. A description of a variety of international models of maternity care is contained in
Annex C.
Factors which influence maternity care provision
A nation's economy and social conditions influence how much emphasis is placed on the health service and the nature of maternity care provision. Some countries place a heavier fiscal priority on areas other than health, and in countries where maternity services have a high priority, mortality and morbidity rates tend to be lower. Prosperous countries (e.g. Ireland, France, Canada, Australia) are more likely to invest in maternity services, whilst the poorer countries (such as Russia and India) may not have the resources or appropriate manpower to deliver a quality maternity service. The importance of maternity services to the public health agenda cannot be underestimated: 99% of maternal deaths occur in developing countries and, for every woman who dies, a further 30 will suffer some form of morbidity that will impact on the health of the family.
Health and welfare services: the nature, management and funding of the health service will influence the provision of maternity services. Countries such as Sweden, Norway, UK, Australia, Canada and USA tend to provide all women with a variably funded maternity service. Some countries have particular demographics or a specific philosophy of care (Sweden, The Netherlands, Canada, New Zealand), which influences how maternity services are provided. The type of maternity welfare benefit available to women and their partners impacts on maternity care provision and uptake and varies greatly from country to country: Spain and Ireland provide approximately 14 weeks of benefit and specify that at least 4 weeks of the leave must be taken prior to the birth. Alternatively, Norway provides a maximum benefit of 42 weeks at full pay or 52 weeks at 80%: this leave can be divided by the parents, but the mother must take the initial six weeks following the birth. In the UK, all employees are entitled to 18 weeks statutory maternity leave.
Professional involvement and approaches to pregnancy and childbirth differ across nations, but tends to reflect the health system and philosophical approach to pregnancy and childbirth. Where a medicalised approach to childbirth exists, the obstetrician provides the majority of care with some support from obstetric nurses or midwives during the intrapartum period and hospital stay. Midwives tend to be the lead professional where a sociological approach to birth exists, in many instances as part of a structure of combined care. Implicit in descriptions of maternity care seems to be an acknowledgement of the role of anaesthetists and paediatricians. The role and participation of the GP in maternity services is varied and may be related to education, manpower and demographics. Significant GP involvement in maternity care is only evident in countries including Ireland, UK, Finland, Holland Australia and New Zealand, although the nature of their input varies from country to country. Other medical and nursing personnel and Allied Health Care professionals play a crucial part in the delivery of maternity services, but do not tend to be acknowledged in the literature. In order to circumvent manpower problems, some countries provide maternity care courses for professionals working in remote areas.
The role of midwives and obstetricians can also differ. Most western countries now recognise the midwife as the most appropriate lead professional to deliver maternity care to low risk women and many have amended funding methods and contracts to reflect this. Others utilise specially trained nurses to provide ante- and postnatal care, whilst ensuring that midwives are the main professionals providing intrapartum care: the dilemma of achieving continuity of carer is superseded by ensuring sufficient midwifery manpower to provide skilled intrapartum care. Where there are no obstetric manpower problems, obstetricians are responsible for the majority of maternity care irrespective of the level of risk. Spain, Luxembourg and Greece have a similar number of obstetricians to midwives and, not surprisingly, the obstetricians provide the bulk of the care. The pre-requisite for maintaining clinical competencies are rarely explicit although certain countries have key criteria for maintaining registration and continuing to provide maternity care.
International evidence suggests that many maternity care professionals base their provision on avoiding litigation, generally through early intervention: USA and Ireland have a litigation culture, which greatly impacts on service provision and outcome.
Private health care and its impact on the provision of maternity services: in many instances, especially but not exclusively in the wealthier countries such as USA and Ireland and irrespective of the quality of State maternity care, women opt to be cared for privately. The type of private health insurance and the nature of payment, influences the choice of lead professional, the nature and philosophy of maternity care and the duration of stay in hospital. In Ireland, the UK, Australia, USA and Canada, private insurance companies identify obstetricians as the clinician to be responsible for maternity care with the insurance covering a limited postnatal hospital stay. Consequently, many midwives have a reduced role and may be no more than obstetric nurses. Intervention rates are high with early hospital discharge, usually without any form of postnatal support. Norway and Sweden provide maternity care for all women under a State health scheme with a strong focus on normality, and maternal and neonatal outcomes are good.
In some western countries the nature of private maternity care is the single biggest influence in the model of maternity care provision. If the private insurer specifies that the obstetrician should be the lead professional (e.g. Ireland), then it is likely that there will be a medical approach to pregnancy and childbirth irrespective of risk. Conversely, if the insurer enables the woman to choose her lead professional (e.g. Holland, New Zealand) then low risk women have the opportunity to be cared for by the professional of choice which may be midwife, GP or obstetrician. Advances in the provision of clinically effective maternity services may be hindered because of the funding model and nature of maternity care. It may be difficult to effect change in the models of maternity care provision unless accompanied by amendments to public and private pay structures and an emphasis towards women-centred care, rather than the provider driven focus.
Philosophy of care and partnership working: in countries where a medical model of maternity care predominates, intervention rates tend to be high and midwives have a diminished role, impacting on nature and quality of care provision. Midwives are in a difficult situation as they lack status, power and in some countries professional recognition to influence change. A sociological approach to maternity care combined with a partnership working, which includes other organisations, institutions and professionals has benefits especially in terms of manpower, service provision, professional development, maternal choice and outcomes.
Many countries are using the available evidence to support the enhancement of midwifery roles and responsibilities, whilst others continue to have an obstetric led service. Sweden and Finland do not have an integrated midwifery service and while outcomes are good, there is a paucity of evidence related to satisfaction. Finland use skilled nurses to provide elements of ante and postnatal care with seemingly good outcomes. Countries experiencing manpower problems are seeking alternative solutions to existing models of care, including the use of maternity care assistants (Netherlands) and developing multi-professional courses for professionals involved in remote maternity care, (Canada, Australia) with enhanced referral and communication pathways and partnership working locally, regionally and nationally.
The review of international models of maternity care highlights the strengths and limitations of the existing models in Scotland, which has an infrastructure able to support change and service re-design. A partnership approach to care is supported, while there is a recognition that innovative working and service redesign must be seriously considered. The majority of countries put the woman at the centre of care and wherever possible provide locally accessible services, in particular for low risk women. Not all countries strive to deliver the seamless approach favoured by Scotland, nor is it possible to obtain quality outcome data thus making valid comparison difficult.
Summary
This international 'snapshot' of maternity services provides an interesting contrast with the Scottish model of maternity care. Countries with robust outcome data such as the Netherlands, Norway and Sweden seem to have attractive models of care, but the transferability of such models to the Scottish situation is questionable due to differences in demography, culture and expectation. Comparison and evaluation of different models of maternity care is difficult due to many variables including culture, demographics, manpower, education and funding. Many countries do not have the quality assurance mechanisms and outcome data that exists in Scotland. Countries are concerned about the increase in intervention rates and the impact that this has on public health and the subsequent health of the family. In order to sustain and build on the existing models and potential of maternity care, professionals must work in partnership developing the appropriate infrastructure, support and referral pathways to ensure a patient centred, seamless and quality of care provision.