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

Chapter Five: New Model Of Care 

There is high quality evidence to support the implementation of a model of care that provides continuity of carer throughout the maternity journey. Midwifery continuity of carer models have proven benefits in terms of improved outcomes for women and babies. Where women require additional care from the wider maternity team, it is even more important that they have continuity of carer from others involved in their care to build effective relationships. Women's desire for greater continuity of carer came across strongly in all surveys and consultations with service users as part of this Review.

5.1 Continuity of carer

Implementing a continuity of carer model challenges traditional approaches to NHS maternity care provision, requiring a substantial shift in resources to community services to deliver care which follows the woman and family.

'It worked on a team system, so although I didn't see the same midwife every time, I saw one of four on the team and this team followed me up after birth as well, so you got to know them all.'

Scottish Maternity Care Experience Survey: 2015

5.1.1 Proposed continuity of carer model

In the redesigned continuity of care model, all women will have continuity of midwifery carer from a primary midwife. The primary midwife will have a buddy midwife who can support her and provide cover for annual, and other, leave and by a small group of local community midwives who will support labour and birth, unless elective operative delivery is required.

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. GP practices will nominate a link GP from the practice to provide a liaison point for the midwifery and obstetric team and will also provide some continuity of support and advice as needed to community midwifery and health visiting teams.

Specific details of the way in which continuity is managed are likely to vary across settings (e.g. urban or rural) and population groups (e.g. women with particular social vulnerability). Different ways of providing continuity should be audited and evaluated.

The primary midwife will normally have a caseload of approximately 35 women at any one time and be the first point of contact for women in pregnancy. She will undertake the booking history, then plan and provide the majority of the woman and baby's care across antenatal, intrapartum and postnatal care working from the community setting. The midwife will link in with the wider health and social care team as required.

In line with the approach of person-centred care, primary midwives and, where appropriate, obstetricians will discuss place of birth from booking and throughout pregnancy with the woman. The primary midwife will support the woman in her decision-making as her pregnancy progresses, and these conversations will be recorded in a shared plan. The approach will remain flexible to address changing needs and expectations at every stage. The planning will include consideration of expectations of post birth care, with the final decision on place of birth-based on the situation at the start of labour.

Where women have additional needs and require input from the obstetrician and wider team, the primary midwife will work in partnership with that team and provide continuous care for women and families. Women who need the input of an obstetrician, will have continuity of a primary obstetrician throughout their antenatal and postnatal care. For most women antenatal care will be offered in their local community. For some women the most appropriate place to have their antenatal care will be in hospital-based clinics. The primary midwife should remain allocated to these women to support their hospital-based antenatal care.

When a woman begins her labour, the primary midwife will normally be the first point of contact for assessment, by phone or in person. A small group of local community midwives will support this process to ensure 24/7 cover. The midwife will then be with the woman for labour and birth, whether at home or in a midwife or obstetric unit. Where an operative birth is planned, this will be provided by the core hospital midwifery team.

During pregnancy, postnatal care arrangements will have been discussed. Women and babies who are well may be discharged shortly after birth, in which case the midwife present at birth would normally arrange discharge and follow up. Where women and babies require admission to a postnatal ward after birth, care will be provided by the core hospital midwifery team, with the primary midwife fully informed and aware.

The primary midwife will plan and provide postnatal care in the community, undertaking postnatal checks of mother and baby, including routine examination of the newborn, in partnership with support staff and GPs as necessary. The care of women and babies will normally be transferred to the health visitor from 10 days after birth, depending on the family's needs, with the GP providing ongoing care throughout.

Where women and babies require admission to a postnatal ward after birth, care will be provided by the core hospital midwifery team until discharge back to the care of the primary midwife.

5.1.2 What does this mean for our workforce?

The existing midwifery and obstetric workforce will be reconfigured to work in a way that supports continuity of care for all women. The majority of midwives will work within the community setting to provide continuity of carer, with a small core team of midwives deployed within the hospital setting to provide inpatient antenatal and postnatal care, and a level of intrapartum support. This new model of care represents a fundamentally different way of delivering services and, thus, further detailed planning will need to be undertaken in partnership with staff to design the new service and ensure a sustainable model is implemented.

Education and support for all staff will be needed to adapt to the new way of working. Additional training may be required for community-based midwives, for example in caseload management, provision of individual elements of the care journey, and routine examination of the newborn. The new employer-led model of clinical supervision will provide additional support for all midwives with this transition through facilitated reflective practice. To prepare staff to work differently, additional resources will be required to develop and implement national approaches to training and education that can be delivered in NHS Boards-based on assessment of local geography and population needs.

RECOMMENDATIONS
1	Every woman will have continuity of carer from a primary midwife who will provide the majority of their antenatal, intrapartum and postnatal care and midwives will normally have a caseload of approximately 35 women at any one time. Where women require the input of an obstetrician in addition to midwifery care, they should have continuity of obstetrician and obstetric team throughout their antenatal and postnatal care. Midwifery and obstetric teams should be aligned around a caseload of women and should be co-located for the provision of community and hospital-based services. Early adopter NHS Boards should be identified to lead the change in practice. Implementation should ensure appropriate education, training and development and realignment of resources is achieved, recognising the potential for additional resources to be required during implementation.
2	Every woman will have a clear birth plan developed for her needs, which is updated regularly throughout her maternity journey.
3	GP practices should nominate a link GP for the practice to provide a liaison point between the midwifery/obstetric team, the health visiting team and the practice.

5.2 Person-centred maternity and neonatal care

The vision for maternity and neonatal services across Scotland is one where all mothers and babies are offered truly family-centered and compassionate care, recognising their own unique circumstances and preferences.

The benefits of keeping mothers and babies together, and of family-centred care, are clear, including:

• facilitating bonding and attachment and, therefore, the development of the family unit
• enabling breastfeeding
• reducing anxiety through good communication
• empowering parents, by maximising their opportunities to look after their infants and making wraparound services accessible for those who need them

It has been clear during the Review process that families want to stay together throughout the maternity and neonatal care journey, including during pregnancy and birth. They want to receive their care as close to home as possible, although there is recognition that, for some aspects of care, there will be a need to travel, depending on the particular situation.

Under any circumstances, women want to receive their postnatal care as near to their baby as possible, and they want more opportunities for skin-to-skin care with their baby. Women have also consistently indicated that they would value the presence of their partners with them in the early days of their baby's life, whether in maternity or neonatal care. The importance to mothers of compassionate and respectful care is clear, as is the provision of relevant information on all aspects of care to allow them to make informed choices.

A number of NHS Boards highlighted their approach to family-centered care, including the provision of accommodation for partners following the birth of their baby and for families with babies in neonatal care. In addition, in some areas, parents are being supported and encouraged to lead the care of their newborn.

5.2.1 New model of person-centred care

It is essential that services regard mother and baby as one entity and truly put the mother, baby and family at the centre of service planning and delivery. This fundamental theme runs throughout this report, and every recommendation is predicated upon it. This means that, at every stage of the postnatal journey, no matter how complex the care, the mother and baby should stay together and barriers to this occurring should be removed.

5.3 Family-centred care

Focusing on women, partners and families at the centre of care planning empowers them to be involved in, and committed to, decisions about their care and that of their baby. Maternity should be co-designed with the mother 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.

Fathers and partners should be routinely offered the opportunity to participate in discussions and decision-making during care and parents should be encouraged and supported to have a leading role in routine care of their baby.

Neonatal care should be co-designed with parents. Parents should provide as much practical care as possible for their baby, and be involved in decision-making throughout.

5.3.1 Support and accommodation for families

There is a clear need to examine in a systematic manner the facilities and support that is available to mothers and wider families.

Facilities are available to accommodate partners in postnatal care in some areas, but provision is not uniform and further attention is required to this important area which would benefit families and also provide some assistance to staff in supporting mothers.

Keeping Families Together

In some pregnancies complications can arise. In Mrs B's case, she had a difficult pregnancy and suffered high blood pressure. This resulted in her being induced early. Her newborn daughter had some difficulties in her first few hours and she and her mum were quickly transferred to the transitional care unit for additional care.

'I received phenomenal support from the staff when expressing milk, tube feeding and even bathing my tiny daughter. They gave me lots of advice, emotional support and outstanding care to enable me to bond with my daughter. They encouraged me to do as much of my baby's care as I could.'

Mrs B's husband stayed with them at the hospital and over the course of the following days, the staff celebrated small achievements with the parents as their daughter became healthier and supported them emotionally when minor setbacks occurred.

'It was great having my husband stay with us on a couple of occasions. This enabled us to bond as a little family. The support we received assisted our transition home greatly.'

Source: Patient Opinion

Many NHS Boards already provide accommodation for women who have to travel to access maternity care. However, this is not universal and this provision should be available in all NHS Boards receiving women who have long distances to travel to access specialist services.

Neonatal facilities should provide sufficient emergency overnight accommodation on the unit for parents with babies in neonatal care, with alternative overnight accommodation being made available nearby for parents of less critically ill babies. There should be facilities for parents to allow them to be on the unit with their babies as much as possible, including facilities for kangaroo skin-to-skin care and breastfeeding/breastmilk feeding.

This Review also recognises that there is not currently uniformity of local policies to support travel, accommodation and living expenses for these families. An urgent national approach to this issue is required to avoid undue hardship for families and to provide a truly person-centred service.

5.3.2 Information for parents-to-be

We heard about the importance of seamless communication and consistent information for families and that this was improved where there was continuity of care and carer. Families found conflicting advice challenging and described examples in relation to a range of issues, including breastfeeding. We heard about the need for nationally consistent information to support families with decision-making, for example in relation to place of birth.

Early access to antenatal education improves outcomes in maternity care. Antenatal education is important to promote positive health behaviours and support parenting. High quality prenatal and antenatal education must be available to all, and NHS Boards should continue to promote and improve early access to antenatal education, including parenting, physical and emotional wellbeing, tailored to local populations.

In Scotland, the Ready Steady Baby ^[47] publication gives a range of information to new parents around pregnancy, birth and looking after a new baby. A project to redevelop the Ready Steady Baby and the Ready Steady Toddler ^[48] resources for parents is underway. The redesign of Ready Steady Baby will take account of the findings of this Review.

In addition, the development of complementary evidence-informed web or app-based tools should be developed to maximise the accessibility and supportive decision-making around place of birth.

While having national resources can support choice and decision-making, all maternity professionals have a critical role in ensuring that women and families have timely and evidence-based information at any point in their journey which is tailored to their unique circumstances. The continuity of carer midwifery model will significantly improve communication and contribute to reducing variation in information.

Involving Partners

Many women told us of the benefits of having their partner stay with them in hospital after giving birth as this helps to promote family attachment and bonding and they welcome the additional support with personal and baby care.

For Mr and Mrs A, they felt that their experience post birth could have been better. After his wife gave birth to a baby girl by caesarean section, Mr A was able to stay with his wife and new baby all day, however he was asked to leave the maternity ward at 9pm.

'I was keen to be on hand whenever my wife needed me to do anything for her and to support her emotionally, pass her our daughter for feeding, and to change her nappy. During the first night of my wife's stay, she was able to buzz for help and a midwife or support worker would usually come and help.'

Mrs A decided to stay in hospital for a second day as she was in a lot of pain. Her husband was on hand to help out during the day however after he left that evening his wife got very little help. There didn't appear to be many staff on the ward for the night shift and a lot of women and babies needed looked after.

Their daughter wouldn't sleep, his wife got no sleep and she needed emotional support and help with the baby. At one point Mr A called the ward to ask if he could come and get them but was told that this was not permitted during the night.

'The staff did their best and they did it warmly however the maternity ward should be set up so partners can stay to help. I could easily have slept in the chair to be next to my wife and daughter.'

Source: Patient Opinion

5.3.3 What does this mean for the workforce?

Whilst the overall approach to care will need to adapt to the new model, the primary delivery skills of compassionate care, treating women with dignity and respect, and the value of good communication are already well embedded within the NHS.

RECOMMENDATIONS
4	Parents of babies in neonatal care should be involved in decisions about the care of their baby and in providing as much care for their baby as possible.
5	Maternity and neonatal services should be redesigned to ensure mothers and babies stay together.
6	All units should take a flexible approach to the presence of partners, to ensure that families can stay together, with suitable accommodation being provided and facilities to enable kangaroo skin-to-skin care and breastfeeding/breastmilk feeding.
7	All neonatal facilities should provide emergency overnight accommodation on the unit for parents, with accommodation available nearby for parents of less critically ill babies.
8	To reduce variation, an urgent review of the approach to expenses for families of babies in neonatal care should be undertaken to develop a nationally agreed policy.
9	High quality prenatal and antenatal education must be available to all, and NHS Boards should continue to promote and improve early access to antenatal education.
10	The redesign of Ready Steady Baby should reflect the new model of care and provide unbiased, consistent, evidence-based information about maternity and neonatal care.

5.4 Multi-professional team working and pathways to care

Evidence suggests that there should be a universal model of care that runs across the whole care continuum, whereby all women and babies receive normal midwifery care (the continuity of carer model) and those with additional needs receive extra care, in conjunction with midwifery care.

Care will aim to optimise normal processes and avoid unnecessary intervention. Where women have additional care needs, care should be provided by a multidisciplinary team with the appropriate skill mix to care for a woman's individual needs, integrated across all settings.

Evidence has identified the importance of effective multidisciplinary team working and culture on the normal birth process and the Morecambe Bay Report highlighted the negative contribution to pregnancy and newborn outcomes caused by a dysfunctional team. During this Review, women and healthcare professionals have described some examples of disjointed care where lines of communications could be improved.

Since 2009, risk assessment of pregnant women has been defined by the current NHS Quality Improvement Scotland Pathways for Maternity Care. These pathways are used to determine the type of care (obstetric or midwife-led) that women should receive. Staff and women have indicated that the existing national pathways for maternity care are perceived as too restrictive and not reflective of current maternity care, with too many women categorised as high risk and little potential for transfer either way between pathways once allocated at antenatal booking.

The importance of individualised, person-centred care and continuity of carer has already been highlighted, however a more systematic approach to person centred care will ensure that:

• Care is tailored to individual need.
• Care is provided by a well-organised team.
• Communication systems and processes are improved to ensure all professionals, including primary care teams, have up to date information.
• Referral systems are seamless.

5.4.1 Model of multi-professional team working

Multi-professional team working is an essential component of high quality care as outlined within the overall vision for the future.

The maternity journey is different for every woman, with some women requiring the involvement of a range of professionals in their care, with others requiring only midwifery care. It is proposed that there is a move away from the terminology associated with high/low risk care and midwife-led/obstetric-led care to redefine the new model in terms of continuity of carer and personalised team care. Risk assessment should become a more flexible and consistent tool to support a woman's pregnancy journey in partnership with the woman. This revised approach will require significant alterations to the current ways of working.

Antenatal care:

Routine antenatal care will be provided by the primary midwife. The midwife, in conjunction with the woman, will identify and agree referral pathways to ensure all aspects of a woman's circumstances are considered and addressed, including personal and lifestyle factors - a 'whole-person' approach.

Women who have complications will also see their primary obstetrician at points in the pregnancy journey, with the obstetrician and midwife finalising the care plan with the woman in order to provide co-ordinated and effective team care. This team care should be extended for women with additional care needs to include GPs and a wider range of medical or social care professionals, as required.

In a very small number of cases of women who have rare conditions of pregnancy or pre-existing conditions, or of babies with rare conditions, care may involve input from professionals who operate at a regional or national level, but again, this should be integrated with the work of the multi-professional team.

Obstetric ultrasound:

Obstetric ultrasound is a normal aspect of pregnancy care for all women, to date the pregnancy accurately at the 'booking scan' and to assess the fetal development at the 'fetal anomaly scan' at 18-22 weeks gestation.

In addition to the routine scans, women who choose to have screening for chromosomal disorders such as Down's Syndrome will be offered first trimester combined screening using a combination of fetal nuchal translucency assessment and maternal blood tests carried out at 12-14 weeks gestation.

A multidisciplinary team is required to deliver obstetric ultrasound. The majority of scans are performed by trained sonographers from either a radiography or midwifery background, with a smaller proportion of medical sonographers.

For several years there has been a recognised workforce shortage in trained sonographers, and this needs to be addressed at a national level, in addition to increasing the numbers of midwives with essential scanning skills.

Care during labour and birth:

In many cases, this will be provided by the primary midwife or the small team associated with her care. However, when women have additional or complex needs, or where medical intervention is needed, this will involve the wider team, including core hospital midwives, obstetric and anaesthetic input, and possibly a wider professional team for the most complex cases.

Postnatal care:

The primary midwife will provide postnatal care for mother and baby at home or in the community. For women and babies who have more complex needs or postnatal care requirements, the wider NHS and, where necessary, social care team will be involved, coordinated by the primary midwife.

In line with the proposed move to the continuity of carer model, the primary midwife will be a consistent presence throughout the woman's care journey, and will co-ordinate, in partnership with the named obstetrician where appropriate, access to any additional care required.

5.5 Redesigned personalised care

The existing care pathways will be revised to reflect a genuinely person-centred, individualised model of care, with the aim of moving away from categorising large groups of women as high or low risk, or care as midwife-led or obstetric-led. The approach will be based on a personalised care plan which is jointly reassessed regularly throughout the maternity journey. The personalised plan will describe the care being jointly agreed with the woman, and will include any appropriate wider team input.

This new continuous needs assessment approach will support and enable continuity of midwifery care, and focus on pregnancy and birth as a normal, physiological process. For women with additional needs, the continuous needs assessment will enable them to receive care from obstetricians and other professionals, tailored to their needs, in a multi-professional team care approach. The new personalised care plans should be kept under regular review to take account of emerging evidence.

5.6 Multi-professional working, culture and behaviours

Effective communication and good interpersonal skills are essential components of high quality care. A number of reports have identified challenges in relation to this issue.

The MBRRACE UK Report - Saving Lives, Improving Mothers Care: 2014 ^[49] identified a lack of leadership in regard to care for women with multiple care needs, leading to women receiving inconsistent information and a lack of clarity over who should be involved in care. Difficulties in communication between primary and secondary care and between different levels of secondary care were also noted. Effective communication is a critical element of high performing teams.

It is important that women and families receive consistent advice and information, and that there is continuity of information between professionals and across levels of care. The role of the primary midwife will be important in supporting this process.

The Report of the Morecambe Bay Investigation: 2015 also focused on the important influence of workplace culture and behaviours on the quality and safety of the clinical care being provided, in particular during labour and birth.

A review of evidence and data identified the core principles for multi-professional working as:

• Effective communication between staff and sectors being essential, including access to clinical information and records.
• The need for trust and respect, and understanding of respective roles.
• Open and honest communication and support for challenge and disclosure.
• Shared opportunities for education and training.
• A need for clear and consistent advice for women and families.

Across NHSScotland, much has been done to promote the standards of behaviour that are acceptable and expected in each NHS Board, and to tackle bullying and harassment in the workplace. However, it is clear that further work would be beneficial to ensure that a revised approach to multi-professional team working truly does become the norm within effective, supportive teams providing excellent care, every time.

Existing programmes and frameworks are in place to develop multi-professional working and a positive, professional, person-centred culture in the NHS. In addition, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have launched an Undermining Toolkit ^[50] for improving workplace behaviour, which seeks to address the challenge of undermining and bullying behaviour in maternity and obstetric services.

5.7 New model of multi-professional working, culture and behaviours

The new model of care has mothers, babies and families at its centre. Work on improving multi-professional working, culture and behaviours will assist in building a healthy relationship between professionals and across NHS Board and professional boundaries. The proposed shift in care from hospital to community services will mean that the emphasis on team working across extended areas and good communication will become even more critical.

Strong and collective leadership is important to the development of a positive work environment, and senior staff across all disciplines have a role to play in describing the standards of behaviour required, demonstrating and promoting positive behaviours and tackling poor behaviours when they arise.

During the Review process, many examples of positive leadership cultures were demonstrated within NHS Boards. However staff indicated the need to further develop this important area to ensure that high performing teams are in place in every area in Scotland.

Teams require to develop a clear understanding of respective roles and competencies within the team, with shared goals in terms of care and service provision. Regular opportunities for contact, collaboration and sharing of information will encourage closer working, and will support learning and a greater understanding of each other's roles. Shared learning and development has been highlighted as a key aim of staff in many areas and, where it has been implemented, staff have spoken very highly of its positive impact.

5.8 Role of the third sector

The third sector provide vital support services to families across a wide range of issues, including peer support for breastfeeding and support for a range of families with specific needs. Staff, service users and third sector organisations have stated that there should be a more consistent mechanism to raise awareness of the services provided in order to ensure they are easily accessible to those who would benefit from their services. There does, however, require to be a clear mechanism to ensure staff can have confidence in the quality and legitimacy of the services being provided, to ensure they meet the needs of individual families.

A number of the larger NHS Boards have developed local directories or registers of third sector services that help staff to systematically inform families of the services available. A more systematic approach to such directories within NHS Board areas may assist in promoting these invaluable services, recognising that it is a significant undertaking to ensure they remain relevant and up-to-date.

5.9 Workforce implications

In order to ensure high performing teams are in place in every part of the system, multi-professional team working will need to be strengthened, again recognising that, in many areas, it is already evident and working effectively.

The new models of care will require an even greater level of team working and, therefore, there will require to be a systematic approach adopted to this important area of development within each NHS Board area. This process will require to involve professionals across a range of services, within NHS Boards, across NHS Board areas and with other public and third sector partners.

The importance and effectiveness of multi-professional team training has been highlighted and should be a model for all continuous professional development and skills development training. Multi-professional educational opportunities should also be explored at undergraduate and postgraduate level.

RECOMMENDATIONS
11	The 2009 Pathways for Maternity Care should be revised at a national level to facilitate an individualised approach to the management of risk through the development of a personalised care plan which is regularly reassessed.
12	The new model of care is based on the absolute requirement to have high performing, multi-professional teams in place, and all NHS Boards should ensure that these teams are developed, and supported, to operate effectively and that this team development is afforded the highest priority at NHS Board level. Multi-professional team education and training opportunities should be explored and should include all levels of staff within NHS Boards.
13	A directory of third sector services, available to maternity and neonatal service users, should be created, in partnership with third sector providers in order that all staff are aware of local and national level third sector support for families.

5.10 Accessible and appropriate local services

5.10.1 Community-based care

NHS and other public sector community services are continually evolving and are likely to change more rapidly over the next few years as a result of the integration of health and social care ^[51] . This will facilitate a move to a higher level of integration of professional teams, based on shared objectives, and increased co-location.

Women have indicated that routine services should be delivered as close to home as possible, to minimise disruption to normal family life and to avoid time consuming and stressful travelling.

In maternity and neonatal care, it is intended that integrated team care will, over time, take place in local community 'hubs'. These hubs would be local care settings for a range of services, designed around the needs of the service user. A community hub would become a facility where people feel they can identify with the services delivered from the hub, in an environment where they feel comfortable.

Community hubs should be designed on the basis of a local needs assessment to ensure they meet the needs of localities, rather than offering one standard model.

Ideally the hubs will include, for example, extended opening hours for appointments, and may, in some cases, include birthing facilities. Women will access the majority of their antenatal and postnatal care in these hubs, which may include scanning facilities and most midwives will work from these hubs.

Each NHS Board should undertake an individual assessment of the viability, scope, and potential impact of hubs within local areas to ensure that the hub meets the needs of localities, while balancing access needs and ensuring resources are used to their maximum effect. It is anticipated that a number of the community hubs will utilise accommodation currently housing freestanding midwifery units, while others may be located in community premises or other public sector premises. A national review of the functioning of these hubs should be conducted in due course, after they have been in place for a defined period.

Women with complex care needs may require to have some care provided in the hospital setting where there is access to a wider range of facilities, but, where possible, a significant proportion of services should be delivered through the hubs.

RECOMMENDATIONS

14

NHS Boards should redesign maternity services with a focus on local care, built around the concept of multidisciplinary community hubs, with the majority of women being offered routine care and services through these hubs. Each NHS Board should undertake a local assessment of the viability, scope and potential impact of hubs identifying local needs balanced with maximising benefit from resources. A review of the functioning of these hubs should be conducted , following an agreed national framework, after a defined period of operation.

5.10.2 The care journey, place of birth and choice

Evidence from a range of sources suggests that most women would seek to labour and birth as close to home as possible. Currently most NHS Boards are able to offer the choice of home birth, birth in a midwifery unit or birth in an obstetric unit.

Many services also offer a range of birthing aids such as birthing pools and hypnobirthing, and women have spoken very positively about the ability to access these services.

Evidence indicates that for women without complications, giving birth in a freestanding midwifery unit ( FMU) or alongside midwifery unit ( AMU) is as safe as obstetric units. For women without complications who are having second or subsequent pregnancies, home birth is as safe as birth in an AMU, FMU or obstetric unit. There is also good evidence that the provision of a less clinical, more homely environment for all women can reduce the use of interventions in labour and improve women's satisfaction, with no adverse impact.

However, at present, very few NHS Boards actively promote home birth as a realistic choice and in many areas, there is no clear differentiation between midwife and obstetric-led care, with both types of care being offered in the same place, with little, or no, differentiation of service. In addition, women have indicated that there is limited information available on the range of choice available to them to allow them to make an informed decision about their preferred location of birth.

5.10.3 Place of birth

The revised approach to continuity of carer and the holistic approach to multi-professional team care have been recurring themes throughout this Review process and these apply equally to the antenatal, intrapartum and postnatal periods of care.

A truly person-centred labour and birth would support the development of a woman's own abilities in a relaxed, mobile and supportive birth environment. This overall approach would assist in developing a trusting relationship with care providers and play an important part both in improving outcomes and in reducing the need for intervention.

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:

1. Home birth
2. Birth in an alongside or freestanding midwifery unit
3. Obstetric unit birth

Each NHS Board area in Scotland should ensure that they are able to provide the full range of choices , either within their own Board area, or, in the case of island Boards, through an agreed arrangement with a mainland Board. Obstetric and midwifery care can be provided in one unit, but with the development of an ethos and environment of homely, comfortable, low tech care without the overt presence of medical equipment. The precise configuration of units should be tailored to local needs, as rural locations will have quite different considerations than those in urban settings.

All birth settings should be comfortable, provide privacy and dignity, and promote active labour and birth, encouraging mobility. In addition to the range of place of birth options, all NHS Boards should aim to provide a range of pain relief for women, such as birthing pools, hypnotherapy, aromatherapy and epidural analgesia. The birth setting should support the normal birth process, regardless of where birth takes place, and will help women to maximise their natural capabilities for childbirth.

National, evidence-based information should be made available on the range of birth settings to support women's choice. In addition clear information in relation to services available locally should be provided for women.

The decision about place of birth should be made jointly by the woman, their primary midwife, and obstetrician in the case of women with more complex needs.

Where possible, women should be supported and encouraged, using available evidence, to aim for a normal delivery, free of intervention. Women without complications should be encouraged to consider birth in an alongside or freestanding midwifery unit. Those women with a previous vaginal birth and without complications, should be encouraged to consider home birth as an option. For some women, decision-making will need to be revisited during the pregnancy as circumstances change, but the emphasis should be on joint decision-making.

It is expected that, over time, this will lead to an increasing number of women being supported to have midwife-only care and a decreasing rate of intervention.

5.10.4 Type of birth

Much of the debate around place of birth focuses on the potential risks associated with childbirth, which can lead to apprehension for some women around birthplace choices. Although most women reportedly want a natural birth, the caesarean section rate in Scotland continues to rise in most NHS Boards, and is variable across Scotland.

There are a number of possible reasons for this rise, including women with increasingly complex pregnancies and births, safety of surgical intervention, and increased awareness of risks.

Whilst many of these interventions will be necessary and lifesaving, there is likely to be a proportion that are avoidable, as evidenced by the levels of variation. Factors contributing to the rising caesarean section rate should be examined, from both the clinical, and women's, perspective and optimal levels of intervention that balance risk and potential harm identified, in line with the Chief Medical Officer's Annual Report 2014-15: Realistic Medicine and the National Clinical Strategy for Scotland: 2016.

Birth in all settings requires well trained and supported staff, good decision-making, and the ability to respond appropriately to changing circumstances. The presence of a known and trusted carer, a skilled midwife backed up by a supportive multi-disciplinary team, mobility in labour and availability of a range of pain relief methods are all factors which will encourage a normal birth. All women should be cared for in a way that supports and encourages them, and builds their self-confidence.

For some women, the safest option will be a delivery by caesarean section, either agreed in advance or as an emergency procedure. Caesarean delivery should only be provided if clinically indicated, and women should still experience continuity of midwifery care throughout, and after, the birth.

It is essential that women have the opportunity to discuss fully their preferred birth plans with their primary midwife, and obstetrician if needed, well in advance of the birth date in order that they have ample opportunity to consider the options, discuss their preferences and have all the information they require to make an informed choice.

No matter what type of birth, the immediate post birth period is a critically important time for family bonding. Post birth skin-to-skin care is already very well established throughout Scotland, and should continue to be promoted. Parents should also be able to enjoy a period of peaceful, uninterrupted time with their baby immediately post birth to promote bonding and attachment.

5.10.5 Sustainability of choice

Many NHS Boards already have freestanding midwifery units which are operating effectively and provide an excellent service. Some NHS Boards are, however, observing a decline in birth numbers in these units.

It will be important to seek to maximise the potential of these units, both in terms of intrapartum care, but more widely, they may act as the focal point for the proposed community hubs.

NHS Boards should undertake an assessment of the viability, and scope, of freestanding midwifery units against an agreed national framework to ensure consistency. This should be considered in conjunction with local service users, with a view to balancing access needs with the need to ensure resources are used to their maximum impact. These local assessments could be undertaken across traditional NHS boundaries where geographical considerations lend themselves to this approach.

In addition, in most NHS Boards there is a decline in the home birth rate. However, numbers are increasing in those areas where home birth is being actively promoted, and where there is a dedicated home birth team.

The aim of this Review is to describe a new model of care that all women should receive, however, in view of Scotland's unique geography and demographics, it is not necessarily appropriate to describe a single uniform model. It is for individual NHS Boards to design and redesign services in their area to fit with the model.

The key recommendation from this Review is that all NHS Boards should provide all women with a full range of choice of place of birth and that this choice includes the options, as outlined above, of home birth, midwife-led care and a hospital birth. The essential elements being the provision of a relaxed and supportive environment for care that promotes natural, person-centred childbirth.

RECOMMENDATIONS
15	Each NHS Board should ensure that they are able to provide the full range of choice of place of birth within their region. National, standardised core information should be made available on the range of safe birth settings to support women's choice.
16	All NHS Boards should aim to provide a range of pain relief for all women.
17	Caesarean delivery should only be provided if clinically indicated and factors contributing to the rising caesarean section rate should be examined, from both the clinical, and women's, perspective, with optimal levels of intervention that balance risk and potential harm being identified.
18	In conjunction with service users, NHS Boards should undertake an assessment of the viability, and scope, of freestanding midwifery units against an agreed national framework to ensure consistency, with a view to balancing access needs with the need to ensure resources are used to their maximum impact.

5.10.6 Post birth care for well mothers and babies

Currently many women go home very shortly after birth, or have a short inpatient stay in postnatal care (one to two days). All women will receive postnatal care in the community, from their primary midwife (or buddy) and, where necessary, their GP, and will usually be discharged from midwife care around 10 days after birth.

A number of women indicated during the Review that their experience of postnatal care in hospital could be improved. While positive experiences were described, other instances were outlined when staff had limited time to support women and their babies. Evidence suggests that the introduction of the continuity of carer model is associated with higher maternal satisfaction after delivery and thus, the implementation of this new model would begin to address some of the concerns. In addition, evidence also suggests that early discharge can be safely achieved.

Women will discuss their postnatal expectations with their primary midwife as part of the antenatal birth planning process to ensure it meets their needs and preferences. In routine circumstances, families should be encouraged to go home as soon as possible following birth. Women who stay will receive care from the core team of hospital of midwives and support staff-based in the hospital.

The mother and baby will continue to receive postnatal care in the community from midwives, with the frequency and content agreed with their primary midwife on the basis of need. The new model of community care, including community hubs, will include a role for support staff and they will assist midwives in the provision of personal care for the mother and baby, including breastfeeding support and parenting skills.

5.10.7 Women with additional postnatal care needs

A number of women and babies with additional care needs may need to stay longer in hospital for clinical care. Immediate postnatal care will be provided by the wider team of core hospital midwives, obstetricians and other professionals.

RECOMMENDATIONS
19	Options for postnatal care should be discussed with women throughout pregnancy and a plan agreed which takes account of their unique circumstances.
20	For the majority of women, all key processes should be aligned and streamlined to ensure early discharge is the norm.
21	The provision of high quality routine postnatal care should be afforded a high priority, with staffing models being reviewed in conjunction with the introduction of the continuity of carer model.

5.10.8 Post birth care for mothers and babies with moderate additional care needs

The greatest proportion of babies currently admitted to neonatal units comprise late preterm (34 - 36 ⁺⁶ weeks gestation) and term infants with moderate additional care needs. The number of these babies is increasing nationally and this increase is anticipated to continue ^[52] . Late preterm infants commonly require a moderate additional level of support to maintain temperature and establish breast, or formula feeding, and they more commonly require treatment for jaundice.

Currently, many of these babies are admitted to neonatal units but, most of them could be cared for with their mother on postnatal wards, or even at home, with additional support. This type of transitional care arrangement would keep mother and baby together and reduce neonatal unit admissions of both late preterm and term infants.

Those units which have operated a model of postnatal neonatal care or transitional care report shorter stays for mother and baby and increased breastfeeding rates, with improved quality of women's experience.

Transitional care, offering postnatal care for mothers and enhanced care for the baby, should be offered as a care level in all units in Scotland, with care being delivered primarily by an integrated team, with the midwife as the primary carer. Neonatal care would need to be delivered by a team of in-reach staff from a neonatal unit to work with parents and maternity staff, to provide care for these babies. In line with the model of family centred care, parents should be encouraged to provide as much care as possible or their baby, and staff will support parents to develop the skills and knowledge that they need.

'We benefited from transitional care which allowed me to return to hospital. My daughter and I were then cared for by the specialist unit for three days. This was very good and gave my husband and I confidence in caring for our daughter.'

Scottish Maternity Care Experience Survey: 2015

Clear pathways of care, admission criteria, discharge planning and clinical guidelines would be required, underpinned by education and training, to ensure this model is implemented appropriately, with a system of data collection on postnatal neonatal care and audit being developed to evaluate the process.

5.10.9 Routine examination of the newborn

Routine examination of the newborn is an important part of the care of all babies. It offers an opportunity to detect congenital abnormalities, and identify problems which can be treated or avoided by prompt intervention. It is generally undertaken within the first 72 hours of life and has traditionally been performed by junior medical staff.

It is essential to ensure that the routine examination of the newborn is undertaken to a high standard by appropriately trained staff, with findings properly recorded and appropriate action taken.

With appropriate training, midwives can include examination of the newborn during routine care. Some NHS Boards have already provided training for midwives to conduct this examination, which offers greater flexibility for the baby and mother and often facilitates an earlier discharge home. It also offers an opportunity to explore any concerns which parents have about their new baby, and to offer general advice and support.

GPs routinely provide mothers and babies with their post birth check at six to eight weeks post birth, and this should continue to be part of routine postnatal care.

RECOMMENDATIONS
22	Well, late preterm infants and term infants with moderate additional care needs should remain with their mothers and have their additional care needs provided on a postnatal ward by a team of maternity and in-reach neonatal staff. Clear pathways of care, admission criteria, discharge planning and clinical guidelines would be required, underpinned by education and training.
23	The routine examination of the newborn can, in most cases, be undertaken by appropriately trained midwifery staff, with an appropriate audit and governance mechanism in place to evaluate the outcome.

5.11 Infant feeding

The decision on how to feed their baby is one of the most important early decisions faced by a new mother. Breastfeeding provides positive health benefits for the breastfed infant, the mother, wider family and society as a whole. Some of the benefits are immediate, individual and short lived but many also persist throughout life. For example, breastfeeding is associated with many benefits for mothers and their babies, including, better protection from acute infections, neonatal enterocolitis and respiratory illness and protection from a range of longer-term conditions and childhood obesity, as well as improved cognitive development. For the mother, the benefits of breastfeeding include protection against breast cancer.

Scottish Government policy has, for many years, sought to increase the rate of breastfeeding. However, societal barriers such as attitudes to breastfeeding in public, high rates of formula feeding in low income communities, lack of support in the workplace, and limited assistance from staff and community services, mean Scotland has some of the lowest breastfeeding rates in the developed world.

During the Review, women reported a range of views on the support they received for breastfeeding. Many women described excellent support and advice, while others reported a lack of postnatal support for breastfeeding, and inconsistencies in advice. In particular, women with babies in neonatal care often felt unsupported. A number of women also reported feeling pressurised to breastfeed, with staff not supporting their choice to bottle feed.

'The midwives and breastfeeding support worker were excellent. I saw the same two or three midwives and they had obviously discussed things in advance, so I was not having to repeat things.'

Scottish Maternity Care Experience Survey: 2015

Good quality breastfeeding support services are best provided by a range of support services to meet the needs of mothers and infants. This may include specialist support from trained and experienced professional infant feeding advisors, core support from midwives and additional support and reinforcement of basic skills from support workers and peer supporters.

All maternity and neonatal units in Scotland have already achieved the UNICEF UK Baby Friendly Maternity and Neonatal accreditation standard, or are working towards it. Units should be supported and encouraged to gain or maintain that accreditation. Maternity and neonatal units should consider how best to provide a postnatal environment that is conducive to supporting effective breastfeeding.

The continuity of carer model aims to build strong and trusting relationships between the midwife and mother, which will provide a more supportive environment for breastfeeding. It is suggested that, to enhance the support currently provided, community-based support staff should be trained and will work as part of the community team to provide additional support for breastfeeding and other infant care. In addition, community hubs will provide more open access to maternity care services locally for women who want advice and support with breastfeeding. Providing the environment to support women to breastfeed will help promote confident parenting and maximise the potential health benefits.

Women who formula feed, either by choice or because of breastfeeding problems should be fully supported and advised about how best to do this while minimising the risks. Staff should ensure that women have adequate information and access to equipment.

RECOMMENDATIONS
24	The new model of continuity of carer, community hubs and enhanced community care will provide an environment to support breastfeeding. Community-based care will include a role for support staff to assist midwives in the provision of baby care, including breastfeeding support and parenting skills, along with care and support for women who formula feed.

5.12 Midwifery across the career framework

Throughout the Review process, midwives have highlighted the lack of opportunities for clinical career progression. In light of a new model of maternity and neonatal care, consideration should be given to whether, and how, clinical midwifery practice across all levels of the career framework could contribute to the provision of care for women and families. It is proposed that this work should be progressed by the Chief Nursing Officer as part of her national work to transform nurses, midwives, and allied health professionals ( NMAHP) roles.

5.13 Equipping the workforce to deliver

To underpin the expansion of care and services needed to support normal birth processes, the general midwifery workforce will need refresher training in core skills which may have lost prominence, including supporting normal birth processes in all settings. A national tailored continuous professional development programme should be developed which can be delivered locally and includes for example, case management, delivering continuity of care and carer, supporting physiological processes, and specific clinical skills. Midwives and other staff will also need to be trained to conduct routine examination of the newborn.

5.13.1 Non-registered workforce

There is currently variation in midwifery and neonatal support worker roles and their skills could be better used. These roles could be more flexible to enable staff to work across maternity or neonatal care and community or hospital settings. With appropriate training, these roles could include:

• Support for public health interventions such as breastfeeding.
• Lifestyle interventions related to smoking, substance misuse, diet and general physical care of mother and baby.
• Family support for parenting, teaching basic skills and providing emotional support to build maternal confidence.

There should be a nationally consistent role description for non-registered support staff, backed up by nationally consistent education.

5.13.2 Staffing a postnatal neonatal care model

In order to support delivery of a new model of postnatal neonatal care or transitional care, maternity and neonatal staff undertaking different roles will require training and development. A new staffing profile would also need to be developed to ensure a shift of resources from the current to the revised model. It is anticipated that this can be undertaken within a similar overall staffing profile.

RECOMMENDATIONS
25	The general midwifery workforce should receive refresher education and training in core skills, including supporting normal birth processes and providing care across the whole care continuum, and in examination of the newborn.
26	Consideration should be given to the development of clinical midwifery roles across the career framework as part of the national work to transform nursing, midwifery and allied health professional roles.
27	A revised staffing profile for inpatient postnatal maternal and neonatal care should be developed collaboratively by maternity and neonatal care providers, underpinned by staff education and training in relation to postnatal maternal and neonatal care.

5.14 Specialist services

5.14.1 Specialist maternity care

A small number of women with the most complex care needs, will need to access highly specialist care for themselves (maternal medicine), or their baby (fetal medicine), or both. In line with other evidence in relation to low volume, high risk conditions, and the National Clinical Strategy for Scotland: 2016, it is likely that these women and babies will have better outcomes if their care is managed by a core group of consultants at a regional or national level, depending on the complexity.

Women with these complex needs should still receive continuity of midwifery carer from their primary midwife and primary obstetrician, who will co-ordinate the multidisciplinary team care around the woman.

Specialist services may also be required during labour and after birth (high dependency care and intensive care).

5.14.2 Maternal medicine

An increasing proportion of women are requiring additional specialist medical input either from their obstetrician or from another medical speciality because they either enter pregnancy with a medical condition not related to the pregnancy, or develop a medical condition during pregnancy. This requires coordinated care across a wide range of health services to ensure timely multidisciplinary joined-up working with women and health care professionals.

Most of the time this degree of medical care will be able to be provided at their local consultant-led unit but, for a very small number of women, this may require regional or national centres to be involved depending on how unusual their medical condition is.

Where there is a requirement for other medical specialty input, this should be from an identified named physician in that medical speciality, with an interest in pregnancy who meets and cares for the woman, with her obstetrician, during pregnancy. Input needs to occur in a timely manner recognising the pregnancy timeframe, and continue into the postnatal period. There is currently significant variation in this type of care provision.

Women may also present to acute hospital settings with medical needs. They may be seen in an obstetric triage setting or may present and be admitted through other acute settings e.g. emergency departments. Reports such as MBRRACE have highlighted critical delays in obstetric review of unwell women who present at non maternity settings and variation in approaches to care ^[53] , which have contributed to poor outcomes.

Where women present outwith maternity settings they should be reviewed by the maternity team in a timely manner to ensure pregnancy-appropriate medical care occurs at all times, in all locations. Standards for this should be agreed nationally.

5.14.3 Fetal medicine

Fetal medicine is a specialist service to care for a baby's complex needs before and around the time of birth. It must be multidisciplinary and holistic in its approach to the care of women who have suspected or confirmed fetal disorders, or a relevant history in a previous pregnancy. As with maternal medicine, many of these needs can be met locally by the obstetric and neonatal team, but sometimes care is required at a regional or national level depending on the complexity of the condition, from paediatric specialist services (e.g. Paediatric surgery, cardiology) or geneticists. Each unit must identify a lead obstetrician who has, or who will develop, appropriate expertise in fetal medicine. There must be ongoing good communication with, and information for, parents as well as robust referral pathways in each NHS Board to ensure strong links between local and regional/ national centres.

5.14.4 Co-location of most specialised levels of care

For women and babies with the most complex care needs (maternal or fetal medicine), this care should be managed by a core group of experienced consultants at a regional or national level, supported by clear protocols and an agreed rapid referral and appointment process. To ensure high quality and consistent information is given about rare or complex maternal or fetal conditions, it is recommended that standardised information leaflets are given to parents during antenatal discussions.

'Mrs T had a known identical twin pregnancy when she presented to the maternity unit at Dumfries and Galloway Royal Infirmary at 17 weeks gestation. A scan performed there suggested that one of the twins was in heart failure due to severe twin-to-twin transfusion syndrome. She was referred to the Fetal Medicine Centre at the Queen Elizabeth University Hospital ( QEUH) in Glasgow where she was reviewed the next day. A further scan confirmed the diagnosis and she underwent immediate fetoscopic ('keyhole') laser treatment to correct the underlying problem. Both babies remained well following the procedure and she was followed up in Glasgow and also in Dumfries. She remained well however, due to further complications at 27 weeks gestation, her twins were delivered at the QEUH and then transferred to the Dumfries neonatal unit and then home. They are now six months old and continue to do well.'

Source: Patient, Queen Elizabeth University Hospital

The overall approach to the delivery of maternity and neonatal services is based on the key principle that mothers and babies are kept together at all times. Maternity and neonatal services should be organised so that units providing the most highly specialised care are co-located.

This will support the development of professional and unit expertise and minimise the separation of a baby and their family when both a mother and baby require specialist care.

RECOMMENDATIONS
28	Where a woman has a medical condition which requires additional specialist medical input, this should be provided in a timely manner from an identified named physician in that medical speciality, with an interest in pregnancy, and may need to be managed at a regional or national level. Midwifery care should continue throughout from the primary midwife, as part of the multi-disciplinary team. Units providing the most specialised maternity and neonatal care should be co-located.
29	Where women present outwith maternity settings they should be reviewed by the maternity team in a timely manner to ensure pregnancy-appropriate medical care occurs at all times, in all locations. Standards for this should be agreed nationally.
30	Each unit must identify a lead obstetrician who has, or who will develop, appropriate expertise in fetal medicine. There must be good ongoing communication with, and information for, parents as well as robust referral pathways in each NHS Board to ensure strong links between local and regional/ national centres.
31	To ensure high quality and consistent information is given, it is recommended that standardised information leaflets are given to parents during antenatal discussions on fetal abnormality.

5.15 Theatre and critical care (high dependency unit and intensive care)

As the demographics and complexity of childbearing women have changed over recent years, the need for increased care in the form of high dependency and intensive care has also increased.

Significant numbers of women need to utilise theatres, high dependency and critical care and, thus, they are an essential and integral element of the service. These need to be appropriately resourced, particularly theatres, where adequate dedicated staffing should be in place with separate workforce staffing for the areas to ensure appropriate levels of trained staff are in place to meet the need of the service.

It is essential that maternity theatres have dedicated theatre staffing. It is also essential that all staff providing this care in theatre, recovery or high dependency are trained to the nationally agreed standards and can maintain relevant competencies to provide the same standard of care as received by the non-pregnant surgical patient.

Women requiring care in intensive care settings should have multidisciplinary input from intensivists and obstetricians, as well as ongoing midwifery care to meet the woman's midwifery needs.

RECOMMENDATIONS
32	Staff providing critical care in theatre, recovery or high dependency must comply with national standards, be appropriately trained and regularly maintain competencies. Adequate staffing levels must be in place within theatres, recovery and high dependency areas.
33	Maternity theatres should have dedicated theatre staffing, and these staff should be appropriately educated, trained and managed.

5.16 Services for vulnerable women

5.16.1 Evidence

Evidence suggests that the early stages of pregnancy following conception are vitally important in terms of infant development and are the time at which the baby is most vulnerable to the impact of adverse maternal circumstances. Pregnancy is also commonly seen as a key time when women may be more receptive to modifying their lifestyle and improving their health and wellbeing for the sake of their baby.

Many women find themselves in a vulnerable position for a wide range of medical, social and psychological reasons with resulting poorer outcomes for both mother and baby. Some of these women will have no other current interactions with health or social care services, whereas others will be engaged with multiple agencies in relation to their own health and wellbeing and the health and wellbeing of others in the family.

Engagement with staff and service users underlined the importance for this group of women to build strong relationships with their midwife, and having continuity of carer. Many NHS Boards have developed bespoke services for women who are vulnerable. Most models are currently based on a reduced midwifery caseload to increase contact time, with the midwife acting as a coordinator to support seamless and multi-agency care around the women and there is good evidence to support this approach.

Evidence also suggests that it is important to have empathetic, non-judgemental staff in these roles who are knowledgeable of the women's individual needs. Effective communication both in terms of interpersonal skills, but also for women with low literacy levels, women who are deaf and use sign language, or where English is not their first language, will also be an essential component of good quality care.

5.16.2 Action for vulnerable women

The key elements of high quality and safe care for vulnerable women are similar to those for other women. However, the intensity of the provision of the care is likely to differ, and the provision of team care is likely to comprise a wider range of clinical and social professionals in addition to third sector workers. There is also a higher risk of negative outcomes if adequate support is not provided to a high standard.

Vulnerability is multifaceted and often variable in its nature and, in order to ensure relevance, local patterns of vulnerability need to be examined and services tailor-made to address these local needs.

All women, and in particular the most vulnerable, should be supported with compassion and with advice and services to promote lifestyle changes during their pregnancy to improve their own health and the health of their baby. It is important to recognise that there are degrees of vulnerability, and that anyone in any part of society can be vulnerable during pregnancy.

It is, therefore, vital that all midwives are equipped, as the first point of contact, to recognise and manage vulnerable women appropriately. The work of the primary midwife is likely to be particularly important for women who are especially vulnerable, and caseloads may need to be reviewed to support this position.

More complex women may require referral into specialist, multi-professional and multi-agency teams, but many women can be supported as part of routine care, with extra support from their primary midwife and the wider team. GPs, as a key part of the team, will provide a vital point of longer term continuity for these women.

In all cases it is important to ensure that the team care is constructed around the women's needs, and is accessible for vulnerable women. It is anticipated that these services will be provided as locally as possible, in community hubs in many cases.

5.17 Workforce and education

Education, training and support for staff will be essential if vulnerable women are to be fully supported and assisted in caring for themselves and their baby.

Midwives who are dealing exclusively with the most vulnerable women will require additional education and training to ensure that they can provide the care needed, particularly in relation to enhanced skills in working with women with multiple vulnerabilities, including alcohol and substance misuse, mental wellbeing, women in the criminal justice system or women seeking asylum or refuge.

RECOMMENDATIONS
34	All NHS Boards should conduct a systematic needs assessment focused on the pattern of vulnerable women of childbearing age in their area and develop specific, targeted services for women with vulnerabilities, with team care constructed around women's needs.
35	All staff should receive a level of training to support them to identify and support vulnerable women as part of routine care, and women with the most complex vulnerabilities should have access to a specialist team. Midwives in these roles will continue to provide continuity of carer and should have a reduced caseload in recognition of the complexity of the women, and will act as the co-ordinator of team care for the woman and her baby.
36	GPs and health visitors must be involved as part of the team in pre and postnatal care, and GP practices should identify a named link GP for vulnerable childbearing women and their babies.

5.18 Perinatal mental health

Many women experience mental health issues during their maternity journey and require additional understanding and support. There is broad policy, public and clinical consensus that early intervention on perinatal mental health will improve outcomes for women, children and families.

It is estimated that up to one in five pregnant women may experience some form of deterioration in their mental health throughout the course of their pregnancy, ranging from a relatively minor presentation to a more serious and enduring illness. Maternal mental health is a significant cause of maternal mortality in the UK, with vulnerable populations being disproportionately affected.

Perinatal mental health has been a consistent theme raised by staff, third sector organisations and service users around Scotland. The need to increase awareness of the issue has been regularly highlighted with particular issues being raised in relation to the access and range of these services provided and the need to improve the skills of staff in this important area.

5.18.1 Perinatal mental health services and care

There is variation in the perinatal mental health support available across NHSScotland. Clearer and more efficient pathways are needed for referral, along with greater access to services. Staff caring for pregnant and postnatal women and their partners should be confident in talking to parents about mental health problems in order to assess and agree the best possible course of action for the woman and her family. Midwifery staff should have these skills to recognise and support women with all levels of perinatal mental health.

While many women can be supported locally, clear, consistent referral pathways are required for women with more enduring, or serious, illness.

For parents of babies in neonatal care, access to psychological support services can assist them to understand and cope with the situation and prepare them to provide the care that their baby needs. Parents have raised the importance of having a range of these services for families with babies in neonatal units.

Improving Outcomes For The Most Vulnerable 

A large number of children in Scotland are born into, and live within, families that are considered vulnerable. In NHS Greater Glasgow & Clyde, a Special Needs in Pregnancy Service ( SNIPS) is provided for pregnant women with vulnerabilities, including addictions to alcohol and drugs.

'Working within the SNIPS Team is highly rewarding. We offer non-judgemental, holistic, flexible integrated care to those deemed to be the most vulnerable, within both the antenatal and postnatal periods.'

The service is comprised of a multidisciplinary team with a dedicated obstetrician, midwives, link midwives for refugee and asylum seekers, teenage pregnancy and homeless families.

The SNIPS multidisciplinary team work collaboratively with social services and addiction services in the provision of care for women during pregnancy and immediately following birth.

'I like coming to the SNIPS clinic because I see the same midwife and I feel well supported in my pregnancy.'

RECOMMENDATIONS
37	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. NHS Boards should ensure adequate provision of staff training to allow staff to deliver services to the appropriate level. Primary midwives, in partnership with primary care colleagues, should play a proactive and systematic role in the identification and management of perinatal mental health care.
38	The Scottish Government should ensure that Perinatal Mental Health is a key focus in the forthcoming Mental Health Strategy, and that appropriate connections are made with the new models of care described here in that strategy.
39	NHS Boards should ensure all neonatal staff can refer parents of babies in neonatal care to local psychological services.
40	All staff in maternity and neonatal units should be aware of third sector support organisations operating in their area and be able to signpost them to women and families in their care.

5.19 Bereavement

Stillbirth, neonatal death and maternal death rates continue to decline, however these deaths still tragically happen. NHS Boards around Scotland have shared some excellent examples of maternity and neonatal units developing staff and facilities to provide support for bereaved families, and for families dealing with palliative care for their babies. Third sector organisations have also reported some of the excellent care and support that they can provide.

We had five precious days with Ramsay in the family room in the hospital. We were able to hold our baby boy, dress him and take hundreds of photographs.

The medical photographer at St John's Hospital, Livingston took pictures and presented these in a lovely photograph album. Photos we will cherish for the rest of our lives. The staff were quietly sympathetic and treated us, and most importantly Ramsay, with nothing but respect.

As we were leaving, we were given a little bag with information inside about SANDS Lothians. This was to become our lifeline.

SANDS Lothians

However, we also heard that these services are not universally available and many families struggle to access the support they need and that parents are often unaware of services available locally. We also heard about how bereavement care may need to be provided for an extended period for many families.

We heard of the value parents put on being able to spend some time with their dying baby at home. Inpatient and community service should integrate end-of-life care pathways to support families in their choice if they would to spend time with their baby at home or in a hospice.

RECOMMENDATIONS
41	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 neonatal unit should have access to staff members trained in bereavement care. Families should also be provided with appropriate information about bereavement services locally, both in hospital and third sector services, and also information on follow up care.
42	Inpatient and community service should integrate end-of-life care pathways to support families in their choice if they would like to spend time with their baby at home or in a hospice.