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

1. Chapter 1: Introduction - The Context of Maternity Care in Scotland

Introduction

1.1. This report presents the national findings of the 2013 Scottish Maternity Care Survey.

1.2. Across Scotland around 58,000 women give birth each year¹ and almost all of them are cared for by NHSScotland's maternity care services. For all women childbirth is a life changing event. For many the experience will be happy and affirming, for others it may be less so but the experience of childbirth is never forgotten and it will have long-term impacts on the health and wellbeing of mothers, babies and families.^{2, 3} Care provided to mothers and babies through pregnancy and childbirth provides a unique opportunity for intervention and education which have the potential to create lasting health improvements and to give infants the best possible start in life.⁴ For this reason the improvement of maternity care and women's experiences of care during childbirth are central to the ambition of NHSScotland to achieve sustained improvements to the health of the people of Scotland.^{4, 5}

1.3. Through A Refreshed Framework for Maternity Care in Scotland⁶ the Scottish Government sets out the following overarching principles for maternity care:

• Reducing inequalities in maternal and infant health outcomes.
• Promotion of maternal and infant health and wellbeing.
• Ensuring that all women have access to safe and effective maternity care.
• Mutually beneficial relationships between those providing and those receiving care as evidenced by respect, compassion, continuity of care, and clear communication and information to support shared decision making.
• Reduction of wasteful or harmful variation in care provision.

1.4. Across Scotland maternity care is provided by multi-professional care teams including midwives, obstetricians, general practitioners, paediatricians, and many more, working through an integrated network of 17 consultant led maternity units and 21 community midwife led units and birth centres. Scotland is geographically and socially diverse and local maternity care services reflect this diversity. However, wherever they live women and their families have a right to expect to maternity care that is consistent with the principles outlined above.

1.5. The last national survey of women's maternity care experiences in Scotland was undertaken around 15 years ago.⁷ Since then maternity services have undergone considerable change both to organisation and infrastructure. Several new maternity hospitals have been commissioned and services in many areas have been reconfigured. Midwife led maternity units provide local community based maternity care and lower 'tech' care alongside larger consultant led maternity units. In recent years there has been a particular focus on supporting normal birth and provision of care pathways appropriate to the needs of mothers and babies through the Scottish Government's Maternity care programme 'Keeping Childbirth Natural and Dynamic' (KCND)⁸ and the Scottish Government Children, Young People and Families policy 'Getting it Right for Every Child' (GIRFEC).⁹

1.6. The quality and safety of maternity services across Scotland are subject to scrutiny at local and national levels through the Scottish Patient Safety Programme, Maternity and Children's Quality Improvement Collaborative,¹⁰ and by measuring performance in relation to the Scottish Government HEAT target on antenatal access to care.¹¹ However many important aspects of care quality can only be assessed by asking women about their experiences of care. Through listening to women and asking about the care they received we can better understand the differences between maternity care policy and maternity care as it is actually experienced.

1.7. The national maternity survey report provides comprehensive information about women's experiences of maternity care in Scotland in 2013. The survey asked questions on each stage of maternity care; during pregnancy, during labour and birth and postnatal care in hospital and at home. Within each of these stages, questions have focussed on issues that have been highlighted in A Refreshed Framework for Maternity Care in Scotland,⁶ in other maternity care surveys,¹² and in research¹³ as being central to improving women's experiences of pregnancy, childbirth and the early weeks at home following the birth. The results of this survey will be used to identify areas for improvement in maternity services and to inform future service developments at local and national levels. While local surveys and consultations with maternity service users regularly take place, it is important to take stock at a national level to provide benchmark data for NHS Boards to identify areas where improvements are required and importantly, to provide those who use maternity services with information about maternity care in Scotland.

1.8. This survey was undertaken as part of the Scottish Government Patient Experience Programme in partnership with the Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP Research Unit). The Patient Experience Programme supports NHSScotland in developing ways to use patients' experiences to inform service design and planning across the health service to drive improvement. Through the Patient Experience Programme, people in Scotland are being given the opportunity to comment systematically on their experience of healthcare and its impact on their quality of life. Find out more about the Patient Experience Programme at: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health. The NMAHP Research Unit is a multidisciplinary national research unit, funded by the Scottish Government Health and Social Care Directorate Chief Scientist Office (CSO). The unit has a remit to conduct high quality applied research that enables Nurses, Midwives and Allied Health Professionals to make a difference to the lives of the people of Scotland and beyond. Find out more about the NMAHP Research Unit at: http://www.nmahp-ru.ac.uk.

1.9. This report presents the national level survey results. Results for individual health boards are available at: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/maternitysurvey/results

1.10. Further data analysis will be conducted to provide a report on variations on experiences of maternity care by different groups of women, for example first time mothers and mothers from different socio-economic groups.

Methods

The questionnaire

1.11. The questionnaire used in the Scottish Maternity Care Survey was based on a maternity care questionnaire developed by the Care Quality Commission (CQC). The CQC questionnaire has been developed, tested and successfully used in three English national maternity surveys 2007, 2010 and 2013 http://www.cqc.org.uk/public/publications/surveys/maternity-services-survey-2013.

1.12. A survey advisory group was formed comprising midwife leaders from policy and clinical practice in Scotland. This group worked with the survey project team to undertake some minor modification of the CQC questionnaire to ensure its relevance to the Scottish context. Wider consultation was then undertaken with the Royal College of Midwives Lead Midwives Scotland Group, members of NHS Lothian Maternity Service Liaison Committee and the Scottish Executive Nurse Directors group. The questionnaire asked women both to report their experiences of key aspects of maternity care and to give an overall rating of the care they received at each stage of the maternity care journey. The rating of care reflects the individual women's evaluation of her care and this will reflect her personal expectations and values in relation to her actual experience.¹⁴ The inclusion of questions on specific aspects of care (continuity, information giving, involvement in care decisions etc.) provides some insights and explanations of women's general rating of care as well as monitoring quality of care against maternity policy targets. A copy of the questionnaire can be found in Appendix i and at: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/maternitysurvey/maternitysurveymaterials.

1.13. The survey has been conducted concurrently with a national survey in England and this will allow for benchmarking of findings. A comparison of survey results is included in Appendix 2.

Sample

1.14. The questionnaire was administered as a postal survey. Questionnaires were sent to 4,964 randomly selected women who gave birth in Scotland in February and March 2013. Women whose babies had died were not included in the survey.

1.15. The sample was stratified by the hospital where women gave birth (with separate strata for home births). The random survey sample was prepared and checked by the NHS Central Register (NHSCR), the Scottish Government Analytical Services Division (ASD) and Practitioner Services Division (PSD). The sample was checked for maternal or baby deaths before mailing of questionnaires. Permission for access to identifiable patient data to send the questionnaire to mothers was granted by the Community Health Index Advisory Group. All data was accessed, managed and stored in accordance with the maternity survey data processing agreement which set out measures to ensure compliance with data protection legislation.

1.16. An approved patient survey contractor (Quality Health Ltd) was appointed to carry out the field work. Posters advertising the survey were distributed to all Scottish maternity units. The questionnaire was issued between April and June 2013. Two postal reminders were sent to encourage mothers to respond and the final response deadline was early August 2013. The questionnaires included an invitation letter and information leaflet in a range of languages and a freepost return envelope. Women had the option to complete and return the paper version of the questionnaire, to complete the questionnaire online or via a telephone helpline in a wide range of languages. The helpline was also available to handle questions or complaints about the survey. Further details of the survey design, fieldwork and analysis are available in the Scottish maternity care survey technical report http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/maternitysurvey/results

1.17. In total 2,366 women returned questionnaires giving a response rate of 48%.

Data analyses

1.18. The survey data were collected and coded by Quality Health Ltd and securely transferred to the Scottish Government for analysis. The completed, anonymised analyses were shared with NMAHP Research Unit in order to produce the national report.

1.19. With the exception of the 'Women who responded to the survey' section, the percentages presented in the report have been weighted in order to increase the representativeness of the results. Weights were applied to all survey responses based on the number of eligible mothers who gave birth in each hospital (or gave birth at home). This means that the contribution of each hospital to the NHS Board and Scotland results is proportional to the number of eligible mothers that gave birth there. Further information on how weights were calculated and applied can be found in the technical report.

1.20. Given that the survey is based on only a sample of mothers, the figures included in the report are estimates for the 'true' figures that would have been found if we had surveyed every eligible mother in Scotland. The confidence intervals, which are included in most tables, provide the range (the 95% confidence interval) within which the true value is likely to lie.

Presentation of results

1.21. In the following chapters results are presented by stages of the maternity care journey; care during pregnancy, care during labour and birth, postnatal care at hospital and at home. Within each chapter results are presented for key themes relevant to the particular stage. Some themes are included at each stage of maternity care for example, communication, information and involvement, and continuity of care. The overall national average results are presented with the range between NHS Boards (highest and lowest) to provide information on variations in women's experiences of care across Scotland. In some sections a distinction is made between results for mainland and island health boards; this distinction has been made because of the relatively small survey sample for some of the island health boards and because of the different organisational arrangements for maternity care operating in these health boards. However, because of the small numbers involved these comparisons must also be treated with caution. A summary for each NHS Board of questions where there is a statistically significant change in the result compared to the national average is included in Chapter 5 of this report.

1.22. Data is presented in frequency tables with a focus on percentages. Different response rates were achieved for each question and where appropriate filter questions were used to direct women away from responding to questions that were not relevant to them. The number of responses for each question provides the denominator for calculation of percentages and this is included on each table and for each question where the denominator changes.

1.23. In general results are shown as the percentage of women who answered each question positively. Percentages for each question are calculated excluding any women from the denominator who did not answer the question or answered "not relevant" or "don't know". Percentages have been rounded to the nearest whole number; in some situations this means that the total percentage does not reach 100%.

Women who responded to the survey

1.24. The age range of women who responded to the questionnaire was 16 to 50. The majority of women were aged between 25 and 34 years (57%) or 35 years and over (28%), with fewer respondents who were aged 24 and under (Table 1). Around 24% of Scottish births are to women aged 24 years and under, and 20% to women over 35 years (http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Births/) therefore it appears that the younger age group is under represented and the older age group over represented in the survey results. For 42% of women responding to the questionnaire this was their first pregnancy, while 58% had had at least one previous pregnancy.

Table 1: Description of survey respondents

Question: What was your age on your last birthday?
	Per cent	Frequency (n=2,322)
Under 24	15	339
25 - 34	57	1,322
Over 35	28	661
Question: Have you had a previous pregnancy?
		Frequency (n=2,326)
Yes	58	1,355
No	42	971
Question: How many babies have you given birth to before this pregnancy?
		Frequency (n=1,362)
None	12	160
1 - 2	80	1,090
3 or more	8	112

Women's self-reported current health status

1.25. Most women rated themselves as having very good or good health (94%). Only 5% rated themselves as having fair health, and 0.3% as having bad or very bad health (Table 2).

Table 2: Self-reported general health

Question: How would you rate your health in general?
	Per cent	Frequency (n=2,330)
Very good	54	1,262
Good	40	943
Fair	5	117
Bad	<0.5	7
Very bad	<0.5	1

1.26. Women were asked if they had a physical or mental health condition that they expected to last 12 months or more. Women who responded yes were asked to rate the extent to which this limited their ability to carry out day-to-day activities. Only 9% of women reported that they had a condition that they expected to last 12 months or more. (Table 3), of these 51% reported that this impacted on their ability to carry out day-to-day activities to some extent.

Table 3: Physical/Mental health condition and illness

Question: Do you have a physical or mental health condition or illness lasting or expected to last 12 months or more?
	Per cent	Frequency (n=2,330)
Yes	9	209
No	91	2,121
Question: If yes, does your condition or illness reduce your ability to carry-out day-to-day activities?
		Frequency (n=208)
Yes, a lot	11	23
Yes, a little	40	83
Not at all	49	102

Ethnicity, religion and sexual orientation

1.27. Around 8% of respondents belonged to minority ethnic groups. This is around double the proportion of ethnic minority groups in Scotland's population as a whole (http://www.scotland.gov.uk/Topics/People/Equality/Equalities/DataGrid/Ethnicity/EthPopMig).

1.28. The most common religious view amongst survey respondents was 'none', with around half of respondents identifying themselves in this way. This is higher than the proportion observed in Scotland's general population (http://www.scotland.gov.uk/Topics/People/Equality/Equalities/DataGrid/Religion/RelPopMig).

1.29. The large majority of survey respondents described themselves as Heterosexual/straight, with less than 0.5% respectively describing themselves as Gay/lesbian, Bisexual and Other (Table 4).

Table 4: Ethnicity, religion and sexual orientation

Question: What is your ethnic group
	Per cent	Frequency (n=2,338)
White	92	2,159
Mixed or multiple ethnic groups	<0.5	10
Asian, Asian Scottish, or Asian British	4	105
African	2	41
Caribbean or Black	<0.5	3
Other ethnic group	1	20
Question: What religion, religious denomination or body do you belong to?
	Per cent	Frequency (n=2,338)
None	51	1,175
Church of Scotland	20	465
Roman Catholic	17	397
Other Christian	8	183
Muslim	3	60
Buddhist	<0.5	11
Sikh	<0.5	7
Jewish	<0.5	2
Hindu	1	14
Pagan	<0.5	2
Another religion (non-Christian)	<0.5	9
Question: Which of the following best describes how you think of yourself?
	Per cent	Frequency (n=2,313)
Heterosexual/straight	99	2,287
Gay/lesbian	<0.5	4
Bisexual	<0.5	11
Other	<0.5	11

Dates and your baby

1.30. Most women gave birth to a single baby (99%) and most (93%) gave birth at term (37 weeks of pregnancy or more). Births were relatively evenly spread throughout the day and night (Table 5).

Table 5: Dates and your baby

Question: Did you give birth to a single baby, twins or more in your most recent pregnancy?
	Per cent	Frequency (n=2,356)	Confidence interval (%)
Single baby	99	2,329	98.4	99.2
Twins	1	25	0.7	1.5
Triplets, quads or more	<0.5	2	0	0.2
Question: What time was your baby* born?
	Per cent	Frequency (n=2,348)	Confidence interval (%)
Early morning (24.01-6.00)	23	537	21.5	24.5
Morning (6:01-12:00)	30	700	28.3	31.6
Afternoon (12:01-18.00)	25	576	23.0	26.1
Evening/Night (18.00-24.00)	22	535	21.0	24.0
Question: Roughly how many weeks pregnant were you when your baby was born?
	Per cent	Frequency (n=2,334)	Confidence interval (%)
Before 37 weeks	7	156	6.0	7.9
37 weeks or more	93	2,178	92.1	94.0

*for twins or more than two babies answers were given for the first birth