Maternity care pathways - clinical guidance and schedule and birthplace decisions leaflet: CRWIA

Introduction

1. Brief Summary

Type of proposal

A decision of a strategic nature relating to the rights and wellbeing of children.

Name the proposal and describe its overall aims and intended purpose.

Revision to the Pathways of Maternity Care: Clinical Guidance and Schedule and development of the Birthplace Decisions Leaflet.

The Scottish Government’s publication “The best start: five-year plan for maternity and neonatal care”, published in 2017, made 76 recommendations for maternity and neonatal care in Scotland. This CRWIA relates to two of these recommendations:

Recommendation 11 of the Best Start is that “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.”

Recommendation 15 of the Best Start is that “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.”

In light of recommendation 11, the Scottish Government has updated the Pathway for Maternity Care Clinical Guidance and Schedule. The Pathway for Maternity Care sets out the core contacts clinicians will have with pregnant women and is to be used primarily by midwives and obstetricians.

It has been developed in partnership with a working group of clinical experts, reflects the latest evidence, and will support delivery of the maternity care pathway.

The main principle of the revised Pathway is that routine antenatal care will be provided by the primary midwife who, in conjunction with the woman, will identify and agree a plan of care to ensure all aspects of a woman's circumstances are considered and addressed, including personal and lifestyle factors - a 'whole-person' approach.

We are not proposing the introduction of a new clinical pathway, significantly changing the number of appointments a woman receives, or introducing a radically different approach in the provision of maternity care in Scotland. The revisions to the guidance, schedule and leaflet do not constitute a new strategic decision, a new action plan, major new policy proposal or new legislation. Therefore, the parameters of this CRWIA will focus on the changes/ additions this update to the Pathway and leaflet brings in.

The changes made to the Pathway of Maternity Care include:

• Removing the categorisation of women according to their risk level, and introducing guidance on individualising care for women per her particular needs
• Introducing reference to GIRFEC and the UNCRC, which the Scottish Government has incorporated into Scots law, and applies to everyone up to the age of 18. Before birth, midwives and maternity professionals can apply the values and principles of GIRFEC and support to the parents in considering their wellbeing, and that of the unborn baby. Following birth, the UNCRC captures children’s rights and articulates them within the context of a child’s life and experiences. Midwives and maternity professionals should consider that GIRFEC and the duties in the UNCRC (Incorporation) (Scotland) Act 2024 will also apply to young parents up to the age of 18.
• Updating content to bring it in line with latest NICE guidelines for antenatal, intrapartum, and postnatal care.

In response to recommendation 15, the Scottish Government, in partnership with a working group, has developed a new Birthplace Decisions leaflet which provides information to parents-to-be to help them make their decision about where to give birth.

The new leaflet includes:

• Clear, national-level information about the range of choices of place of birth which may be available for women, and their right to choose.
• Information about things a woman may wish to consider when choosing her place of birth, including types of pain relief available. (As recommended in The Best Start.)
• Suggested questions women may wish to discuss with their care provider so they can make an informed choice.

Start date of proposal’s development: The Best Start recommendations were made in 2017. Working group established and begins work in 2019.

Start date of CRWIA process: August 2024

2. With reference given to the requirements of the UNCRC (Incorporation) (Scotland) Act 2024, which aspects of the proposal are relevant to children’s rights?

The proposal may affect children and young people, both when they are born, and if they become a parent under the age of 18 and access maternity services, therefore this has the potential to impact article 24, the right to health and health services.

Since 2009, risk assessment of pregnant women has been defined by the current NHS Quality Improvement Scotland (QIS) Pathways for Maternity Care. These Pathways are used to determine the type of care (obstetric or midwife-led) that women should receive, and the antenatal risk identified through the Pathway is a factor when identifying the place recommended for birth. People may choose to give birth in a different place than the pathway recommends, the pathway does not mandate where they can give birth but provides them with information on where would best meet needs in terms of individual’s antenatal risk. The revised pathway focuses on a person-centered approach to risk, requiring a GIRFEC wellbeing assessment to be undertaken, and plan reviewed throughout pregnancy.

3. Please provide a summary of the evidence gathered which will be used to inform your decision-making and the content of the proposal.

During the development of The Best Start, staff and women indicated that the existing national pathways for maternity care were 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.

In response to the feedback, Recommendation 11 of the Best Start was drafted: “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”.

An expert group was convened to undertake the work to revise the 2009 NHS QIS Pathways for Maternity Care Guidance and Schedule. As part of that work, a literature review was commissioned and undertaken by the University of the West of Scotland to identify any new evidence surrounding place of birth choices and care for pregnant woman with a range of medical or social considerations in line with the requirements.

Following this, the expert group, whose members included clinical experts, educators, the Senior Medical Officer for Maternity and Women’s Health (Scottish Government), and the Chief Midwifery Officer (Scottish Government) developed the revised care Pathway. The revised care Pathway is also underpinned by the National Institute for Health and Care Excellent (NICE) guidelines on intrapartum (NG121) and postnatal care (NG194).

The Pathway constitutes national guidance on clinical expectations at scheduled visits. It should be used in conjunction with any local guidelines currently in place within Health Boards.

Any additional care required will be directed around a woman, with the woman and her primary midwife remaining at the centre. The guidance also maps out the core postnatal care a woman and her baby will be offered. It clarifies what should take place at each postnatal visit, explains that care can be tailored to meet women’s needs. The guidance for this section has been informed by current clinical guidelines and best clinical practice, through the Scottish Government’s Senior Medical Officer for Maternity and Women’s Health. The Best Start also identified that evidence-based accessible information and decision aids for women, families and health professionals should be developed to enable real choice of place of birth. While teenage pregnancy rates have reduced in the last decade, those living in the

areas of highest deprivation still have teenage pregnancy rates three times higher than those in the least deprived.

Young parents tend to have poorer perinatal health outcomes, higher than average feelings of isolation and low self-esteem, significant socio-economic disadvantage in

terms of lower educational qualifications and lower employment levels and lower

income.

The risk of poverty is higher in families where the mother is under 25 years of age.

4. Further to the evidence described at ‘3’ have you identified any 'gaps' in evidence which may prevent determination of impact? If yes, please provide an explanation of how they will be addressed.

No.

5. Analysis of Evidence

The revisions to the Clinical Guidance and Schedule and Birthplace Decisions Leaflet have been made to reflect the Scottish Government’s broader policy for maternity and neonatal care to be designed around the needs of women and families, as set out in the 2017 Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland’.

To move to a more person-centred approach, the Pathway has been revised to set out that a woman’s primary midwife, in conjunction with the woman, will identify and agree a plan of care to ensure all aspects of a woman's circumstances are considered and addressed, including personal and lifestyle factors - a 'whole-person', individualised care approach. With the expert group, Scottish Government has also updated the Birthplace Decisions leaflet to provide up-to-date information women need to make informed decision about where they would like to give birth.

The revisions made to the guidance, schedule and leaflet will mean that the way care is delivered by healthcare staff will change to reflect the whole-person approach. For example, at appointments midwives/obstetricians will revisit the plan of care, in consultation with the woman. The revisions made also update the terminology use, moving away from high/low risk care and midwife-led/obstetric-led care to the model of continuity of carer and personalised/individualised team care.

The guidance also includes information for the midwives about additional support young parents should be offered. It refers to the ‘Family Nurse Partnership’, for women aged 19 and under, and reminds midwives that if the child is aged under 16 that local child and adult protection guidelines should be followed. It also reminds the midwife to consider referring to the relevant school nursing team if applicable. While these additional support mechanisms already exist, including them in the Pathway highlights them to midwives. This therefore has the potential to positively impact young mothers and relates to UNCRC article 5 and article 24.

We acknowledge that young people from socially disadvantaged backgrounds face inequalities in healthcare, including in maternity care.

Additionally, Scottish Government has a programme of work in place relating to maternity safety and inequalities and a short life working group is in place to address racialised inequalities in maternity care. However as this is separate to the work carried out by this Pathway, the impacts are outside of the scope of this CRWIA.

Over the past six years the rates of pregnancy in young people in Scotland have reduced. This reflects the hard work of professionals and our approach of using evidence-based and effective interventions aimed at young people.

Pregnancy in young people is a complex matter, and supporting young people requires many different agencies to work together both at a national and local level. We know change in this area cannot be achieved by health interventions alone. The Scottish Government’s Pregnancy and Parenthood in Young People Strategy aims to better acknowledge the role that deprivation, inequality and lack of aspiration and opportunity can have. The impact that Community Planning Partnerships can make for young people, particularly with regard to their role in supporting young people to stay connected with education, training, or employment, and supporting young parents around health and social care and housing, is important.

Through the development of the Strategy, the voice of a number of young people on what was important to them, were heard, what they liked and what they would like to see change.

The clinical pathway emphasises the importance of midwives ensuring all the necessary supports and services are brought around the woman. In case of young pregnant women, explicit reference is made to referring to the Family Nurse Partnership and School Nursing, as well as financial support and mental health support services.

6. What changes (if any) have been made to the proposal as a result of this assessment?

Currently, clinicians use the 2009 NHS Quality Improvement Service Pathways for Maternity Care guidance and schedule. With an expert group, Scottish Government has revised this document to reflect latest evidence and the ethos of the Best Start and has made further changes following results of a targeted consultation with clinicians. Previously, the pathway of care a woman was on was determined by her assessed risk level, evaluated at her antenatal booking appointment. This then determined the type of maternity care the woman received.

No further revisions to the Pathway (other than those made by the expert group and following consultation) have been made in light of this CRWIA.