The best start: five-year plan for maternity and neonatal care

Appendix I: Further Research: Recommendations

Recommendations for research priorities and data collection and analysis related to the Review.

Research priorities identified from efficient evidence reviews:

Neonatal care

Evaluation is needed of:

• the effect of kangaroo skin-to-skin care in extremely low birth weight infants in the early days of life (e.g. physiological stability, neurodevelopment and growth) and their parents.
• the new guidelines for Unicef BFI accreditation for neonatal units on infant and family outcomes with an economic analysis of implementing/delivering the Unicef BFI programme.
• different models of care delivery (e.g. early supported discharge and transitional care) on infants and their parents and economic analyses of implementing/delivering the models.
• different workforce configurations (e.g. determining the knowledge and skills required for a particular role/service need and aligning this with the personnel best able to meet that requirement) on infant and family outcomes and associated service delivery costs.

Care across the continuum

• Development and evaluation of group antenatal care to assess its acceptability and effectiveness in a Scottish setting.
• Evaluation of effectiveness, cost-effectiveness, and acceptability of antenatal and postnatal care when provided in the community (either at home or in a community hub/health centre) or in a hospital; including examination of factors such as duration of stay and optimum frequency, duration, intensity and timing of visits.
• The use of telephone/newer technologies to support postnatal care would require further development and evaluation in a Scottish setting.

Care for vulnerable women

• No studies on maternity services for homeless women and sex workers were identified. There was a lack of good quality evidence around care for women from specific vulnerable groups including women with substance and alcohol misuse problems, women from ethnic minorities, women with disabilities and women in the criminal justice system. There is therefore a need to include these populations of women in research on maternity services both in terms of collecting evidence on their views and experiences and development of interventions.
• There is a need for high quality studies conducted in a Scottish setting to evaluate the use of promising approaches to care for vulnerable and disadvantaged women. These approaches could include the use of mobile clinics, link workers in GP surgeries, culturally sensitive community-based lay women support, group antenatal care, broad-multifaceted preterm birth and stillbirth prevention programmes, comprehensive multidisciplinary antenatal and postnatal care with outreach services, comprehensive general antenatal clinical care providing an enhanced range of services, nutritional education, incentives for antenatal and postnatal care use and maternity care co-ordination services.

Maternity care for critically unwell women

• Delivering high quality critical care for women and babies will require models which explicitly take account of the geographical challenges across Scotland. This approach will require the development of models of safe, multidisciplinary and interdisciplinary working. The emergent models must be evaluated to ensure safety and equality of outcomes and experiences.

Interprofessional working

• There was a general lack of evidence on inter-professional working in maternity services, in particular working with other services (e.g. social work, criminal justice system).
• Good quality studies on inter-professional education both at an undergraduate and post-qualifying level are required and in particular should consider the impact on outcomes for women and babies.
• Further development and evaluation for workplace strategies (particularly in remote and rural settings) for improving inter-professional working-based upon the barriers and facilitators identified in this rapid review is required

Place of birth

• Development of 'community hubs' will need development and piloting before wider implementation and evaluation
• To both realise the positive outcomes from increasing use of midwifery-led units for women envisaging a straightforward birth and to meet women's needs, further evidence on the decision-making process around place of birth in Scotland is required. Assessment during pregnancy and after the birth will be needed to fully explore women's views. For example:
  − What information do women receive and what do they need?
  − What sources are most popular and effective?

Continuity of care

• Economic analysis of midwife-led continuity of care is needed.

Data collection and analysis

Scotland is fortunate to have long-established robust national datasets on many aspects of maternal and neonatal health, for example statutory recording of live and still births and deaths and routine health service data on women admitted to obstetric care. More recently established UK-wide enhanced surveillance of maternal and perinatal deaths and various national audits, quality improvement programmes, and surveys are also important.

Despite these strong foundations, room for improvement exists. Over the course of the Review, it has been clear that the available data are not always capable of answering key questions of interest to policy and service development. Specific priorities for enhancement of currently available routine data on maternal and neonatal health are therefore suggested below:

Enhance the existing national record of obstetric inpatient care ( SMR02) to:

• Accurately record specialty (midwifery or obstetrics) and transfers between specialties to enable women receiving different models of care to be distinguished
• Improve recording of pre-existing and pregnancy related maternal morbidities
• Include returns following attended home deliveries

Capture new information on provision of maternal critical care through development of the SMR02 record and/or extension of Scotland's national critical care audit.

Consider options for capturing more 'real time' data on provision of community-based maternity care, for example booking and other antenatal contacts.

Harness the opportunities afforded by all neonatal units across Scotland moving to using the same clinical information system and Scotland joining the National Neonatal Audit Programme to improve the range and quality of national information available on babies receiving neonatal care.

Capture new information on the results of the universally offered newborn physical examination.

Implement a robust, sustainable national congenital anomaly register to allow monitoring of population risk, quality assurance of antenatal screening, and service planning for affected children.

Consolidate Scotland's ability to accurately link records relating to mothers and their children to enable long term monitoring of outcomes across generations. Currently this is constrained as National Records for Scotland is prohibited from sharing specific variables recorded within birth records (in particular maternal date of birth) that are an important prerequisite for efficient and accurate data linkage.