In recent decades the perception of risk has changed from an emphasis on the probability of risk to the current concern with danger and negative consequences (Douglas, 1990). While individuals may be aware of the potential negative consequences of engaging in risk taking behaviours, counteracting other threats may take priority (Wallman, 2000, Wallman 2001). This is particularly evident in maternity services where many women and professionals make choices about their maternity care based on a complex decision making process which includes demographics, provision of service, previous experience, personal circumstances, available evidence, expectations and need as well as risk. Furthermore in assessing and apportioning levels of risk within maternity services it must be acknowledged and highlighted to women, that there is no such thing as 'zero' risk and that risk cannot be the same for every woman. While maternity care experts can measure risk and communicate estimated levels to individuals, this information is filtered and may reflect professional and social bias. Risk perception is an active 'sense-making' process, which depends upon a host of contextual features and which is accomplished by audiences drawing upon collectively-held interpretative resources (Walker, Simmons et al, 1998, Petts, Horlick-Jones and Murdock, 2001)
There is an expectation that maternity care professionals will effectively manage health risk and minimise harm. One aspect of the increased concern with risk and safety within maternity services is the shift from need to risk. Traditionally maternity services have allocated resources and planned services to meet need, but recently there has been a shift from need to risk as a result of increasing concerns about safety and a concern to target services and resources more effectively.
Maternity care differs from other aspects of health care provision because in the majority of cases the clients are healthy and capable of making their own informed decisions about care. However the decisions women make about their care should be based on the best available unbiased information, professional advice and support given at appropriate times during the care episode.
Women can choose where and how they give birth and in many instances a compromise may be required, with need and quality of care taking priority over choice: if their choices are not met then they may opt for a home birth (planned or unplanned). In cases where risk assessment is carried out the key criteria tend to be 'default' criteria and centre on demographics, general medical/surgical health and obstetric history. Little attention is actually paid to the existing evidence base surrounding the promotion of 'normality', which highlights that avoidance of interventions in low risk women has positive outcomes and attention should also be paid to non obstetric-medical risk factors.
Much of the debate surrounding 'small' maternity units focuses on neonatal and anaesthetic support as well as the provision of backup support in emergency situations. Factored into this is access to appropriately trained neonatal carers who have the opportunity to maintain their expertise. In such cases distance to expert help is crucial. The key principals are that as much care as possible should be provided close to the woman's home, and that midwives, and where relevant GPs, should provide an integrated community-based service.
Apportioning risk to levels of care
Risk assessment should be based on exclusion, rather than inclusion, criteria and careful attention must be paid to the changing nature of risk during the pregnancy care episode, managing uncertainty and adopting strategies to minimise risk. Assessing and managing risk within maternity services is a complex and dynamic process and implicit in this is the acknowledgement that there is no such thing as 'zero' risk. Management of care must balance the risks between the available levels of maternity care and informed patient choice and local access. The decisions women make about their care should be based on the best available evidence given at appropriate times during the care episode. Women have the opportunity to make truly informed choices about their care, whilst simultaneously having the professional advice and support of professionals to help inform the decision. In these instances it is vital that there is a clear understanding by both parties of the nature of clinical and non-clinical risk.
Home Birth, stand-alone CMUs and CMUs attached to non-obstetric DGHs should have the
same exclusion criteria, risk management strategy and emergency support mechanisms. It was agreed, that using professionals with little experience of maternity services might in fact increase the risk to the mother and her baby, as interventions may be inappropriate or untimely. If women are led to believe that some form of medical emergency support is available on site, this might lead to an increase in expectations and associated dissatisfaction if expectations are not met. Women who do not fit the criteria for delivery in a CMU may opt to deliver in a CMU alongside a non-maternity DGH in the mistaken belief that there is more support to deal with emergency situations. In exceptional circumstances, remote and rural non-obstetric consultant hospitals (eg islands) may offer caesarean section if facilities and appropriately trained general surgeons and anaesthetists are available. CMUs require an adequate safety net as they no longer have "flying squad" backup for obstetric or neonatal emergencies. Complications in labour will require appropriate consultation, referral and on-site resuscitation and stabilisation by midwives and where relevant GPs.
Access to high dependency care facilities should also be available in all consultant led obstetric units for mothers with systemic illness, who are sick but not requiring intensive care. One in 1,000 mothers requires intensive care, often with life support, most commonly because of haemorrhage, pre-eclampsia/ eclampsia or sepsis and require access to intensive care facilities on-site in a general hospital setting. A maternal resuscitation service, a full obstetric and anaesthetic service and epidural analgesia in labour should be available in all consultant led obstetric units. Each region must provide appropriate levels of maternity care and have a multi-professional and team approach to service delivery.
Non-clinical risk issues must be considered and include:
The exit examples for Levels Ia-d are purposely not all inclusive and these should be considered and specifically agreed locally within the overall network of maternity provision. Any woman with criteria that are listed in Annex E1 under general characteristics, maternal medical and surgical history, poor past obstetric and neonatal history, present pregnancy morbidity should be referred for incremental care. A number of maternal and neonatal morbidities are identified within this Annex which should result in referral for advice regarding management or transfer depending on locally agreed guidelines (
Annex E).
Level IIa-c Maternity Care
All Level II units will provide facilities for low risk women as described in Level I but also will manage more complex conditions, and this will vary depending on the designation of the unit being Level IIa, IIb and IIc. The exit examples are intended as a guide and will vary from unit to unit and should be considered on an individual patient basis depending on geography, existing services, manpower and morbidity. All units should clearly state the level of service offered, allowing mothers informed choice of the type of facility and level of service that they wish for the birth of their baby. These Level II units must have haematology and blood transfusion services available on site. Obstetric anaesthesia and epidural analgesia should be provided on a 24 hour basis. Isolated consultant obstetric units at a distance from general hospitals present difficulties in terms of anaesthetic staffing and access to specialised medical or surgical care and intensive care and stressed the importance of innovative approaches to managing care in these units, working towards location within a DGH site (CEMD (2001)).
Level IIa
Entry to this level of care is similar to Level I and these units consist of a consultant-led maternity unit with <1000 deliveries per annum with no neonatal facility. This type of unit is suitable for healthy low risk women, essentially at term. Women who choose to deliver in Level IIa units will be able to undergo caesarean section, operative vaginal delivery and normally will have access to a limited epidural analgesia service. Although this unit will be able to carry out obstetric intervention, any woman with a significant past medical or surgical morbidity, poor past obstetric or neonatal history and identified current pregnancy morbidities might not be a suitable candidate for delivery in a unit, without adult intensive care or neonatal support. The exclusion criteria for Level IIa care are identified in Annex E2. Once again criteria for maternal or neonatal referrals have been identified.
Referral may be for advice regarding management or transfer depending on locally agreed guidelines. In Level IIa units it is crucial that appropriate referral pathways are used for any mother and baby who gives cause for concern. It is not advisable for any at risk fetus to be delivered in this type of unit.
Level IIb Maternity Care
This refers to a consultant-led maternity unit with <1000 deliveries per annum, with 24 hour paediatric cover and a SCBU. Units of this nature will provide Level II neonatal care (
Table 1.2) and ill neonates will only be transferred after resuscitation and stabilisation, should neonatal intensive care be required. A table of exit criteria for Level IIb care is identified in Annex E3. It is envisaged that a local and regional referral pathway with agreed criteria will be developed and adopted to ensure that all woman and babies receive the highest quality of care as locally as possible. As well as midwives and obstetricians, the skill mix for this level of care will include anaesthetists providing 24 hour cover for anaesthesia, analgesia and resuscitation. Due to the likely workload in a Level II unit, it is envisaged that the obstetric anaesthesia duties will be shared with other duties such as intensive care.
Special Care Baby Units in Level IIb units will have resident paediatric staff. Out of hours this will be a trainee, a non consultant career grade doctor with a minimum of one year's experience in paediatrics including the minimum of 6 months experience in a neonatal intensive care unit, or in some units an Advanced Neonatal Nurse Practitioner (ANNP). Each unit will have a consultant paediatrician with a designated responsibility for direction and management of the unit including the monitoring of clinical policies, practice and standards. Consultants appointed to posts with responsibility for providing cover for Level II b units should have had at least one year of specialist training in a post or posts approved for neonatal training and they should maintain their professional development in the care of newborn babies: this should include regular revalidation in Newborn Life Support.
Referral for maternal and fetal conditions may be for advice regarding management or actual transfer, in line with locally agreed guidelines. Exit examples for Level IIb units are identified in Annex E3. All Level II b units must have clearly identified referral pathways to designated professionals and maternity units for an escalation in intrapartum care.
Level IIc Maternity Care
These consist of consultant-led obstetric units of approximately 1,000-3,000 deliveries per annum (but this may be significantly more) with neonatal intensive care facilities and comprehensive general, specialist medical and support services. These units, while providing all levels of lower risk care, will provide intrapartum care for most woman. Isolated consultant obstetric units at a distance from general hospitals present difficulties in terms of medical staffing and access to specialist medical and surgical care, support care and intensive care should co-locate within DGH sites (CEMD 2001).
Mothers and infants should be transferred to a regional Level III facility if sub-specialist maternal-fetal or specialised medical care is required, particularly from units without adult intensive care. The exit examples for Level IIc care are shown in Annex E4.
Level III Care
These consist of consultant led specialist maternal fetal units of over 3,000 deliveries per annum and will provide care for women with complex maternities, but will also offer a range of intrapartum care options for women requesting low tech care. These units should have on-site adult intensive care, neonatal intensive care (Level IV neonatal facilities) and neonatal surgery, either on-site or close-by. The typical anaesthetic workload in a Level III consultant obstetric unit is identified on page [ ]. The four Level III maternity units in Scotland are capable of caring for the majority of maternal and neonatal morbidities, the one specific exception being the management of hypoplastic left heart syndrome in the neonate which necessitates transfer outwith Scotland. The criteria for transfer to a specialist facility should be at the discretion of the referring hospital following referral, consultation and agreement between the appropriate senior specialists in both units. A list of entry examples for Level III care, in which identified maternal and fetal morbidities are appropriately treated in a specialist centre, are identified in
Annex E5.
Summary
Professional consensus was reached by the Expert Group that maternity care provision in Scotland should be in accordance with the principles identified in the Framework for Maternity Services. While care should be given as locally as possible, it is not feasible to offer all women a locally based comprehensive service irrespective of profile, risk category and demographics: some women may need to travel for intrapartum care. Risk management should be based on exclusion criteria and be an integral part of all maternity services, acknowledging that zero risk attainment is unrealistic in all locations of care.
Many tenets of care within the Framework are achievable irrespective of demographics and these should be provided. The normality of intrapartum care is important, but there should also be a clear and explicit pattern of escalating care with easy and clear transition between the different levels of care, appropriate to the case mix and morbidity within the regional maternity network. All consultant-led maternity units must have a comprehensive emergency support mechanism and access to high dependency or intensive care as appropriate. All CMUs must have basic emergency support to mothers and babies and have appropriate transfer mechanisms identified within the network.
In order to provide a safe, high quality, comprehensive and efficient maternity service in Scotland, a regional approach to planning, management and delivery of care based on local needs and provision is essential within a comprehensive and explicit network infrastructure.