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Implementing A Framework for Maternity Services in Scotland
Introduction
1. Scotland's mix of urban and very remote communities, with some areas of concentrated poverty and disadvantage in our cities and a very dispersed population in some rural areas, presents real challenges to the delivery of maternity services. Women across Scotland have a wide range of needs in pregnancy and childbirth which services must strive to meet.
2. And those needs are changing. Like many other nations in the developed world, Scotland's birth rate is falling. Many women are now waiting longer to have their first baby, and medical and technological advances mean that women with health problems can now be helped to become pregnant and give birth. Over the last 25 years, the length of women's stay in hospital to have their babies has more than halved. Alongside this, infant deaths in childbirth have now become very rare.
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3. These trends seem set to continue. Our maternity services are likely to be dealing with fewer pregnancies and births, but a higher proportion will be more complex, heightening the risk to the mother and/or baby and the potential need for medical intervention. While many women and obstetric professionals believe that the natural process of pregnancy and childbirth has become too 'medicalised', the percentage of women requiring or opting for caesarean section has increased dramatically across the UK, and it is now the chosen method in almost one in five deliveries. These factors all have significant implications for the pattern and nature of acute maternity services across the country.
The Expert Group on Acute Maternity Services (EGAMS)
4. The Scottish Executive Health Department published
A Framework for Maternity Services in Scotland in February 2001. The document sets out a vision for maternity services in Scotland, and provides a 'template' for best practice in maternity care for use by NHS service planners and the clinical professionals who are responsible for delivering these services. It aims to ensure that pregnant women receive care that is not only comprehensive and clinically effective, but is also family-centred, locally accessible, midwife-managed, and based on joint working between primary, secondary and tertiary services.
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5. Following representation from the Royal Colleges of Midwives and of Obstetrics and Gynaecology, the Minister for Health and Community Care set up the
Expert Group on Acute Maternity Services (EGAMS), a short-life working group of professionals and other stakeholders in maternity services in February 2002 (see Appendix 1). This Group was asked to consider how the principles in the
Framework should be applied to care during childbirth, and the services in the acute health care sector which deliver that care.
6. The big question for the EGAMS was how NHS resources, including the obstetric workforce, with all its skills, knowledge and experience, should be deployed to achieve the best balance between:
ensuring choice for women on
where, how and
by whom their care is provided
reducing risk, as far as possible, to the pregnant woman and her baby
ensuring high quality services that offer value for money.
7. It is not always possible to meet women's first choice in relation to their care at childbirth, particularly in some of Scotland's very remote areas. This may also present challenges for services in more populous areas where the pattern of maternity services sometimes reflects past practices, rather than current clinical priorities. EGAMS nevertheless wanted to find means of ensuring that, as far as possible, care delivered to women meets their needs and is close to their home and family, without compromising safety.
The EGAMS' findings
8. The EGAMS prepared a comprehensive reference report which describes the shape of current acute maternity services in Scotland. This reference report describes the challenges and constraints facing NHSScotland in reforming and further developing the service, and sets out a service model to meet current and future needs. The reference report includes:
risk assessment criteria to support clinicians in identifying the appropriate level and location for childbirth according to best evidence about outcomes
advice on the development of midwife-managed care
analysis of the workforce skills and competencies needed to provide acute maternity services in future within the context of a changing environment
staff training needs
a detailed list of existing maternity facilities providing care in childbirth.
9. This overview report summarises the content of the reference report and sets out the strategic vision for developing acute maternity services in Scotland for all relevant stakeholders, including the public, health professionals, health service planners, and political decision makers.
10. The report shows that in 2002, there were 45 healthcare facilities across the country that include maternity units offering intrapartum care. At present, most of Scotland's children are born in consultant-led maternity units. Four regional specialist maternal-fetal units, two in Glasgow and one each in Edinburgh and Aberdeen, deal with the most complex and high risk cases. They also provide general maternity services to their local populations. Over 35% of all babies in Scotland are born in these four units. Of the other units, approximately 20 provide consultant-led services in district general hospitals, some of them quite small, and the remainder are community facilities - Community Maternity Units (CMUs) - providing midwifery-managed care, particularly in remote and rural areas.
11. The report considers the sustainability of some consultant-led acute maternity services in small hospitals. Maternity units with low numbers of deliveries are finding they cannot sustain children's (paediatric and neonatal) services for the few babies who might need them. In some cases, change in the local configuration of other services or shortages in professional staff have already made it necessary for NHS Boards to reshape their local acute maternity services.
12. Changes in the medical and midwifery workforces are already impacting on maternity services. A review of the Scottish medical workforce
3 concluded that increasing specialisation, necessary restrictions on working time and demands to maintain clinical competence through appropriate training and education for medical trainees, make traditional patterns of medical staffing for all acute services difficult to sustain.
13. The EGAMS report concludes that the current configuration of acute maternity services is no longer sustainable. The falling birth rate means that some facilities will not be able to continue in their present form, as small numbers of births do not allow staff to maintain the range and level of skills needed to deal with complex cases or emergencies. Acute maternity services will have to change to reflect sustainable ways of working.
14. To continue to provide childbirth services locally for many women in rural areas and to ensure continuity of individually-tailored care and support, we need to realise the full potential of midwives. One-to-one midwifery care should be the norm for all women in Scotland. The midwife's role should be extended to lead management of childbirth in maternity facilities to provide a local service for low-risk births where women are unlikely to need specialist medical intervention. Such facilities can also provide care for women alongside consultant-led units in hospitals.
15. The complete reference report is readily available to clinicians, NHS strategic and operational managers and other interested people on the Scotland's Health on the Web (SHOW) website -
www.show.scot.nhs.uk.
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