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

Summary Overview

Maternity and neonatal care and services matter to the health and wellbeing of Scotland's people. The health, development, social, and economic consequences of childbirth and the early weeks of life are profound, and the impact, both positive and negative, is felt by individual families and communities as well as across the whole of society.

Within the context of wider change within NHSScotland, this Review offers a unique opportunity to place the current and future needs of women, babies and families, and person-centred, relationship-based care, at the heart of redesigned maternity and neonatal services.

The future vision of maternity and neonatal services across Scotland is one where:

• All mothers and babies are offered a truly family-centred, safe and compassionate approach to their care, recognising their own unique circumstances and preferences.
• Fathers, partners and other family members are actively encouraged and supported to become an integral part of all aspects of maternal and newborn care.
• Women experience real continuity of care and carer, across the whole maternity journey, with vulnerable families being offered any additional tailored support they may require.
• Services are redesigned using the best available evidence, to ensure optimal outcomes and sustainability, and maximise the opportunity to support normal birth processes and avoid unnecessary interventions.
• Staff are empathetic, skilled and well supported to deliver high quality, safe services, every time.
• Multi-professional team working is the norm within an open and honest team culture, with everyone's contribution being equally valued.

This report sets out what this vision will mean for the delivery of high quality and safe maternity and neonatal services across Scotland in the next five years; how women, babies and families will get the type of care they want and how staff will be supported to deliver that care.

It makes a number of recommendations that will change the way that services are organised. The Continuity of carer full table of recommendations is outlined at Appendix A.

Continuity Of Carer

• All women will have continuity of midwifery carer from a primary midwife.
• Midwifery and obstetric teams will be aligned with a caseload of women and be co-located for the provision of community and hospital-based services.
• Specific details of the way in which continuity is managed will vary across settings (e.g. urban or rural) and population groups (e.g. women with particular social vulnerability). Different models of providing continuity should be audited and evaluated.
• The existing midwifery and obstetric workforce will be reconfigured to work in a way that supports continuity of carer for all women.
• Education and support for all staff will be needed to adapt to the new way of working.
• Early adopter NHS Boards should be identified to lead the change in practice.

Person-centred Maternity And Neonatal Care

• Maternity and neonatal care should be co-designed with women and families from the outset, with information and evidence provided to allow her to make informed decisions in partnership with her family, her midwife and the wider care team as required.
• Services will regard mother and baby as one entity and truly put the mother, baby and family at the centre of service planning and delivery.

Multi-professional Working

• There will be a universal model of care that runs across the whole care continuum, whereby all women and babies receive midwifery care and those with additional needs receive extra care.

Safe, High Quality And Accessible Care

• Integrated team care for women, babies and families will, over time, take place in local community 'hubs'.
• All women should have an appropriate level of choice in relation to place of birth and there are a number of choices that should be available to all women in Scotland including birth at home, birth in an alongside or freestanding midwifery unit, and hospital birth.
• Factors contributing to the rising caesarean section rate should be examined, from both the clinical and woman's perspective and optimal levels of intervention that balance risk and potential harm should be identified and implemented.
• Babies with moderate additional care needs (for example, late preterm) should, when possible, be cared for in postnatal wards.
• The provision of high quality postnatal care should be afforded a high priority.
• Achieving this new model of working will require considerable re-design of services, especially in the way that midwives work.
• Maternity and neonatal services should be organised so that units providing the most highly specialised care are co-located.
• Maternal and fetal medicine services for women with the most complex needs should be managed by a core group of experienced consultants at a regional or national level.
• All women, and in particular the most vulnerable, should be supported with compassion and empathy, and provided with advice and services to promote lifestyle changes during their pregnancy to improve their own health and the health of their baby.
• All NHS Boards should review their current access to perinatal mental health services to ensure early and equitable access is available to high quality services, with clear referral pathways.
• In every case where a family is bereaved, they should be offered access to appropriate bereavement support before they leave the unit, and each maternity and/or neonatal unit should have access to staff members trained in bereavement care.

Re-designing Neonatal Care and Services

• Three to five neonatal intensive care units should be the immediate model for Scotland, progressing to three units within five years.
• A national Framework for Practice should be developed which outlines clear pathways for newborn care and also supports the development of consistent and equitable specialty paediatric and allied health professional outreach support for local neonatal units from larger units.
• A national level group should be established to develop National Frameworks for Practice for Scotland, which are evidence-based and describe minimum acceptable standards for newborn care.
• Education, training and development will be needed for all staff.

Supporting The Changes

• Transport services: The transport team must continue to be an integral part of the neonatal community, and effective communication and liaison between neonatal units and neonatal transfer teams should be routine.
• Remote and rural care: It is essential that all staff can access high quality education, training and support and rotation to larger units for skills maintenance.
• Telehealth and telemedicine: The enhanced use of telemedicine in maternity and neonatal care should be developed.
• Workforce planning: NHS Boards should undertake comprehensive workforce planning-based on the new model.
• Education and training: Education and training capacity planning is needed to ensure staff are fully supported to deliver the new models of care.
• Quality improvement: National maternity and neonatal dashboards should be developed.
• Data and IT: A national data hub, integrated with Information Services Division, part of NHS National Services Scotland , should be developed to coordinate the collection and verification of all Scottish related neonatal and maternity data.
• Electronic records: A Scottish electronic women's maternity record should be developed.

Wider Implications

• A single Maternity Network for Scotland should be developed, along with a single Neonatal Managed Clinical Network for Scotland.
• The implementation process should consider the phasing and prioritisation of the recommendations to ensure the implications of the considerable level of service change are managed appropriately.
• A systematic evaluation of the impact of the more significant recommendations should be undertaken.