Having a baby in Scotland 2013: Women's experiences of maternity care

Executive Summary

This report presents the national findings of the 2013 Scottish Maternity Care Survey. The results will be used to identify areas for improvement in maternity services in Scotland and to inform future service developments at local and national levels. The survey questionnaire was based on a maternity care questionnaire developed by the Care Quality Commission (CQC) and used in the English maternity services survey 2013. The CQC questionnaire was modified before use to ensure its relevance to the Scottish context. Questionnaires were sent to a randomly selected sample of 4,964 women who gave birth in Scotland in February and March 2013. Overall 2,366 questionnaires were returned giving a survey response rate of 48%.

The survey has highlighted many areas of good practice and examples where the recommendations of the Scottish Government's maternity care policies are being achieved. At each stage the majority of women's experiences of care were positive. However, the survey also brings to light areas where care may be improved. Some of these are long standing issues which seem resistant to change despite efforts at health policy and practice levels. Multiple factors are likely to form barriers to change; these may include individual and societal attitudes, expectations and traditions as well as service issues and resources. Broader approaches to change may be also required including working with women, families and communities to co-design services and solutions to improve women's experience of maternity care.

Summary of key results

Care during pregnancy: Antenatal care

• 58% of women rated the care that they received while they were pregnant as excellent and 33% rated it as good.
• Most women (87%) reported that they had their first antenatal assessment visit (antenatal booking) by 12 weeks of pregnancy. Only 35% of women saw a midwife first when they thought that they were pregnant.
• Almost all women (99%) said that they were given a telephone contact number for their midwife/ midwifery team and 82% of women who used this number during pregnancy said that they were always given the help they needed.
• 62% of women saw the same midwife for all/ most of their antenatal check-ups.
• Only 56% said that they received enough information to help them decide where to have their baby. 23% of women said that they were given the choice of giving birth in a midwife led unit or birth centre, and 25% of women said that they were offered the choice of home birth.
• 88% of women said that they were always spoken to in ways that they could understand, 82% said that they were always listened to and 83% that they always had time to ask questions.

Care during labour and birth: Intrapartum care

• 73% of women rated their care during labour and birth as excellent and 21% rated it as good.
• Almost three quarters of women reported that during labour they were able to move around and choose positions in which they were most comfortable. 26% said that they gave birth lying flat, and 31% lying flat with their legs in stirrups.
• 20% of women said that they had been left alone when it worried them at some point during their labour or birth, for 10% of women this was during early labour.
• Almost all women (95%) said that their partner or companion was as involved in their care as much as they wanted.
• Almost all women (92%) said that they had a period of direct skin to skin contact with their baby shortly after birth.

Care after birth at hospital and at home: Postnatal care

• 52% of women rated the care they received in hospital as excellent, 31% rated it as good. 58% of women rated the care they received at home as excellent, 33% rated it as good.
• 61% of women were always given the information or explanations they needed while in hospital after the birth of their baby.
• 28% of women said they were sometimes and 5% said they were not treated with kindness and understanding while in hospital after giving birth.
• Only 57% said that they always received consistent feeding advice.
• Half of women said that they saw the same midwife for all, or most of their postnatal care at home and 44% of women said that they saw the same midwife for antenatal and postnatal care either all or most of the time.
• Thinking of the six weeks following birth 78% of women said that they definitely received help and advice about their baby's health and progress.
• Sixty-four per cent of women said that they were definitely given enough information about their own recovery after birth. Only 59% of women said that they were given enough information about the emotional changes they might experience.

Key points

The Scottish Government Heat target for early access to maternity care is that 80% of women will have their first antenatal assessment visit by 12 weeks of pregnancy by 2015. The survey results are in line with other data sources on antenatal access which indicate that this target is being been achieved overall, although not consistently in every health board area. Most women first contacted a health professional at around six weeks of pregnancy. Only about one third contacted a midwife directly. Encouraging and enabling women to take ownership of their care through self- referral directly to maternity services may result in more women having their first antenatal assessment visit before 10 weeks of pregnancy.

Many women said that they were not always given enough information to enable them to make decisions about place of birth and not all said that they were offered a choice. Choices offered will depend to some extent on facilities available within health boards. However, in some areas where all options for place of birth were available less than half of women reported being offered a choice. Only about one in four women were offered the option of home birth and very few women ultimately gave birth at home or in a community midwife led unit. Many factors will influence women's choices about where to give birth including individual and societal concerns about safety of birth outside of consultant led maternity units. Community midwife led units and home birth services must be used to capacity if they are to remain viable. A process of shared decision making with local communities and maternity care providers may help to determine, on a societal level, what choices of place of should be available and how these choices may be facilitated and maintained.

The majority of women said that they had trust and confidence in the staff caring for them during their labour and birth. However, one in five women reported that they were left alone during labour at a time when it worried them, most often but not exclusively, during early labour. Not all women felt that they received assistance within a reasonable time when they called and some felt that their concerns were not always taken seriously. During early labour in particular, there may be a mismatch between the care needs expressed by women and their birth partners and the assessments of maternity care staff and this may lead to anxiety and dissatisfaction with care. Sensitive communication between midwives and women and their birth partners is required. However, broader approaches to helping women understand the physiological process of normal labour and challenging unrealistic media representations of labour as a rapid and dangerous process may also be helpful.

Over half of women reported giving birth either lying flat or with their legs in stirrups. This may be necessary in situations where women give birth assisted by forceps or ventouse. However it appears that a number of women who experienced a normal vaginal delivery also gave birth while lying flat or flat with their legs in stirrups. There is some evidence that these positions may have negative impacts on the physiological processes of birth. Support for normal birth has been a focus of maternity services in Scotland; however, these findings suggest that this remains an area with potential for continued improvement.

Communication between women and maternity care staff appeared to be good at all stages of maternity care. The survey found that when women sought help and advice from the maternity care team particularly during antenatal care and postnatal care at home, most women said they always received it. An exception was postnatal care in hospital when 30% of women said that they only sometimes received the information or explanations that they needed. Overall, advice provided about infant feeding during postnatal care was not always consistent and in the six weeks following birth many women said that they were not given enough information about their own recovery or about possible emotional changes they might experience. There is evidence that many women experience psychological and physical health problems following childbirth; it is essential that all women are given appropriate and timely advice about their own recovery and emotional wellbeing so that they are equipped to recognise potential health problems and to seek help promptly.

A concerning finding was that during postnatal care in hospital one third of women felt that they were not always treated with kindness and understanding. The first few days following childbirth are crucial in promoting mothers parenting confidence, bonding and physical recovery. Key to improving women's experience of care is communication, listening and support; however postnatal care in hospital is often provided in a context of time and workload pressure and this may not enable staff to always provide women centred care.

Continuity of care is central to high quality maternity care and research evidence indicates that continuity of midwife led care can result in improved health outcomes for mothers and babies. The survey found that while more women received continuity of carer during their antenatal care, only around half of women appeared to be receiving the recommended level of continuity of care for both antenatal and post natal care. Within Scotland there are examples of health boards in which higher than average levels of continuity of care is being achieved and these should provide opportunity for sharing best practice.

Recommendations

• Women should be encouraged to access maternity care services directly when they think that they are pregnant. Systems that enable women to easily contact maternity services and that facilitate communication between professional groups should be implemented to support this.
• Women should be provided with unbiased, evidence informed information to help them make informed choices about where to give birth, using decision aids to present risks and benefits of all available choices. Wider consultation between local communities and maternity services should be undertaken to explore concerns and attitudes to place of birth.
• Women's concerns about being left alone in early labour must be taken seriously by maternity care services. Improvements will require both help for women and families to understand and cope with early labour and provision of services co-designed to meet their early labour needs.
• Women should be given information about the potential benefits of using upright positions for birth and enabled and encouraged to do so whenever possible.
• Postnatal care in hospital must be priority area for improvement. It is essential that maternity care in the earliest days following birth is given high priority and staffing resource that it merits if women's experience is to be improved
• During the six weeks following birth all women should be provided with information and advice about their own physical recovery and about emotional changes that they may experience after childbirth.
• Adoption of models of midwife led maternity care that enable continuity of carer should continue to be a priority for the maternity services for both antenatal and postnatal care.
• Further work is required to develop appropriate survey methods tailored to the needs of women who have experienced the loss of their baby and their families as well as those of other groups of women who are less likely to respond to large scale surveys.