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

2. Chapter 2: Care During Pregnancy: Antenatal Care

Summary of key results

• Early access to maternity care - 87% of women had their booking appointment at or before 12 weeks of pregnancy.
• Only 35% of women saw a midwife first when they thought that they were pregnant.
• Accessibility of maternity services - 99% of women reported that they had a telephone number for a midwife or midwifery team that they could contact. 82% of women who used this number reported that they were always given the help that they needed.
• Continuity of care - 62% of women reported that they saw the same midwife for their antenatal check-ups either all or most of the time
• Variation - there was wide variation between NHS Boards for continuity of care and having a named midwife.
• Information and involvement - 78% of women said that they were involved enough in general decisions about their antenatal care. Only 56% of women reported that they definitely received enough information to help them decide where to have their baby.
• Communication - 88% of women reported that they were always spoken to in a way they could understand and 82% that they were always listened to and given time to ask questions about their care
• How women rated their antenatal care - 58% of women rated their antenatal care as excellent and 33% as good.

Early access to maternity care

2.1. A key target for maternity services in Scotland is improved early and direct access to safe and effective maternity care for all women.⁶ Antenatal care brings the majority of women into contact with health care professionals, sometimes for the first time as adults. Where care is accessed in the first twelve weeks of pregnancy there are opportunities for early identification and intervention where there are health or social concerns, as well as opportunities to support mothers to make healthy lifestyle changes (for example to stop smoking).¹⁵ This offers the potential for sustained, long term health and wellbeing improvement for mothers and families.

2.2. There is evidence that women at higher risk of poorer pregnancy outcomes and particularly women from areas of higher socio economic deprivation are the least likely to access maternity care early.¹⁶ Scottish Government health policy recommends that the initial contact with maternity care services will, if at all possible, be made by 10 weeks of pregnancy and that an initial assessment of health, obstetric and social needs (known as the booking assessment) will be undertaken ideally, by 10 and certainly by 12 weeks of pregnancy.⁶ The national HEAT target for early access to maternity care is that 80% of women in each Scottish Index of Multiple Deprivation category (SIMD quintile) will have booked for antenatal care by 12 weeks of pregnancy by March 2015.¹⁷ Women were asked roughly how many weeks pregnant they were when they first sought professional care and how many weeks pregnant they were when they had their antenatal booking appointment (Table 6).

2.3. Over half of women responding to the questionnaire had made contact with a health professional by six weeks of pregnancy (58%) and almost all women (96%) first saw a health professional at or before 12 weeks of pregnancy. There was little variation between health boards.

2.4. Overall, 87% of women had their booking appointment at or before 12 weeks of pregnancy, suggesting that the national HEAT target has been achieved (Table 6). However, there was some variation between health boards: 95% of women in NHS Grampian had their booking appointment at or before 12 weeks compared to 74% in NHS Greater Glasgow and Clyde. All women in the island health boards (i.e. NHS Shetland, NHS Orkney and NHS Western Isles) had their booking appointment at or before 12 weeks of pregnancy. Further analysis is required to determine whether there were any differences in accessing maternity services between socio-economic groups.

Table 6: Access to maternity care

Question: Roughly how many weeks pregnant were you when you first saw a health professional about your pregnancy care?
	Per cent	Frequency (n=2,329)	Confidence interval (%)
0 to 6 weeks	58	1,324	56.3	59.8
7 to 12 weeks	38	916	36.2	39.7
13 or more weeks	4	89	3.3	4.8
Question: Roughly how many weeks pregnant were you when you had your booking appointment?
	Per cent	Frequency (n=2,200)	Confidence interval (%)
0 to 7 weeks	16	342	14.3	17.0
8 or 9 weeks	35	801	33.2	36.6
10 or 11 weeks	19	409	17.3	20.2
12 weeks	18	381	16.3	19.1
13 or more weeks	13	267	11.9	14.4

Accessibility of services

2.5. Early access to maternity care is facilitated where women can contact a midwife directly when they think they are pregnant. The KCND programme⁸ recommended that all women should have the option of a midwife as their first point of contact with maternity care services. Maternity services should be made as accessible as possible; antenatal care should be provided in locations and times that are convenient for maternity service users and there should be clear routes of communication and access to care for women who require information and /or assistance.^6,16 In the survey, women were asked who was the first professional they saw when they thought they were pregnant and whether they had a choice about where antenatal check-ups would take place. They were asked whether they were given a telephone number for a midwife or midwifery team that they could contact and, if they contacted the midwife or midwifery team whether they were given the help that they needed.

2.6. Overall, 35% of women saw a midwife as the first point of professional contact when they thought they were pregnant, whereas for 60% of women a General Practitioner/ family doctor was the first point of contact (Table 7; Figure 1). There was considerable variation between NHS Boards. For the island health boards 60% of the women in NHS Shetland saw a midwife as first point of contact, compared to only 15% of the women in NHS Western Isles. Of the mainland NHS Boards 61% of the women in NHS Ayrshire and Arran saw a midwife as first point of contact, compared to 15% in NHS Greater Glasgow and Clyde.

Table 7: First health professional seen by pregnant women

Question: Who was the first health professional you saw when you thought you were pregnant?
	Per cent	Frequency (n=2,358)	Confidence interval (%)
GP / family doctor	60	1,395	58.5	61.8
Midwife	35	848	33.1	36.3
Other	5	115	4.3	5.9

Figure 1: First point of contact for pregnant women in Scotland

2.7. Overall only 21% of the women reported that they were able to decide where their antenatal check-ups were to take place (Table 8). Again, there were variations across the health boards: 51% of women in NHS Western Isles reported being given a choice of where their antenatal check-ups should take place, whereas 30% of the women were given this choice in NHS Shetland. Larger variations were evident between mainland boards. In NHS Highland 29% of women were given a choice of where to have their antenatal check-ups, compared to 9% in NHS Forth Valley.

2.8. Almost all women (99%) were given telephone number for a midwife/midwifery team that they could contact (Table 8) with little variation across NHS Boards. While most women who contacted the midwifery team reported that they were always given the help they needed (82%), 18% reported that they either only sometimes, or did not, receive the help they needed (Table 8). There were some health board variations. Eighty nine per cent of women in NHS Highland reported always being given the help they needed compared to 76% in NHS Lanarkshire. Of the island health boards 97% of women on Shetland and 88% of women on Orkney reported always being given the help they needed when contacting their midwife/midwifery team.

Table 8: Accessibility of maternity services

Question: During your pregnancy were you given a choice about where your antenatal check-ups would take place?
	Per cent	Frequency (n=2,251)	Confidence interval (%)
Yes	21	479	19.2	22.1
No	79	1,772	77.9	80.8
Question: During your pregnancy, did you have a telephone number for a midwife or midwifery team that you could contact?
	Per cent	Frequency (n=2,350)	Confidence interval
Yes	99	2,327	98.7	99.4
No	1	23	0.6	1.3
Question: If you contacted a midwife or the midwifery team, were you given the help you needed?
	Per cent	Frequency (n=1,922)	Confidence interval (%)
Yes, always	82	1,581	80.2	83.4
Yes, sometimes	16	298	14.3	17.4
No	2	43	1.7	2.9

Continuity of care

2.9. A key principle underpinning maternity care in Scotland is continuity of midwifery care. Continuity of midwifery care has been demonstrated to be associated with positive care outcomes and improved satisfaction with maternity care,¹⁸ and it has been recommended by the World Health Organisation as having an important role in improving maternal and child health.¹⁹

2.10. There has been considerable debate about what continuity of care actually is in practice (i.e. continuity in the way care is given or care by the same person). However, a working definition within NHSScotland is that continuity of care is care that is provided by the same person for all, or most, planned episodes of care. Scottish Government health policy indicates that all pregnant women in Scotland should have a named midwife who provides continuity of care through the antenatal period.⁶ Within Scotland midwives will usually be the lead professional in the care of healthy pregnant women working within a multidisciplinary care team that includes GPs, obstetricians and other care staff.⁸ Women with more complex care needs will receive care led by an obstetrician and the choice of any women to receive care from their GP or obstetrician during pregnancy should be respected.

2.11. In the survey, women were asked which health professionals they saw for their antenatal care. Women who responded that they saw a midwife for their care were asked if they saw the same midwife for every check-up and if this was their named midwife.

2.12. Almost all women (98%) reported that they received care from a midwife during their pregnancy. Sixty two per cent reported that they saw the same midwife for their antenatal check-ups either all or most of the time. Twenty four per cent of women said that they did not have a named midwife (Table 9)

2.13. There was considerable variation between health boards for continuity of midwifery care. Considering mainland boards women were most likely to report having seen the same midwife all or most of the time in NHS Grampian (77%) and least likely in NHS Greater Glasgow and Clyde (43%). Women were most likely to see their named midwife for their antenatal care in NHS Lothian (76%).

2.14. There were also differences between island health boards. In NHS Shetland all women reported seeing the same midwife all or most of the time) and for 97% this was their named midwife, whereas in NHS Western Isles only 21% reported being seen by the same midwife for their antenatal check-ups and only 4% reported being seen by their named midwife (these results must be treated with caution due to the small numbers of births in these health boards during the survey period).

2.15. Overall, 12% of women in Scotland saw their GP/family doctor at some time during antenatal check-ups (Table 9). The percentage of women who saw their GP for antenatal check-ups ranged from 6% in NHS Tayside to 21% in NHS Lothian.

Table 9: Continuity of care in antenatal care

Question: Which of the following health professionals did you see for your antenatal check-ups?
	Per cent	Frequency (n=2,358)	Confidence interval* (%)
Midwife	98	2,309	97.3	98.4
GP (family doctor)	12	293	11.0	13.2
Hospital doctor (e.g. a consultant)	37	873	35.2	38.6
Other	1	29	0.9	1.7
If you saw a midwife for your antenatal check-up, did you see the same one every time?
	Per cent	Frequency (n=2,326)	Confidence interval (%)
Yes, every time	20	448	18.3	21.2
Most of the time	42	1,001	40.7	44.3
No	38	877	36.1	39.5
Was this your named midwife?
	Per cent	Frequency (n=2,153)	Confidence interval (%)
Yes	54	1,156	52.1	55.5
No	22	467	20.6	23.8
I did not have a named midwife	24	530	22.6	25.4

Information and involvement

2.16. The Healthcare Quality Strategy²⁰ highlights that health service-users value, caring and compassionate staff, clear communication and information and effective involvement as well as excellent clinical care. Scottish Government maternity care policy⁶ recommends that throughout pregnancy women and their families should receive clear, balanced and consistent information that enables them to make decisions about their care, specifically including choice of place of birth. The option of providing women with choice of hospital for birth (consultant unit, midwifery led unit or birth centre) depends to some extent on facilities available within health boards and women's willingness to travel as not all options are available within each NHS board. Cross health board travel is possible. However, in some situations the geographical distribution of maternity units and centres of population mean that long distances may be involved. Nonetheless, Scottish Government maternity care policy recommends that all women should be offered the choice of home birth, unless contraindicated for medical reasons. Women were asked whether they were offered choices about where they would plan to have their baby and whether they felt they were given enough information to help them make this choice. They were asked whether they were sufficiently involved in more general decisions about their antenatal care.

2.17. Overall, only 56% of women reported that they definitely received enough information to help them decide where to have their baby (Table 10). Choices about planned place of birth are particularly relevant for women living in rural and remote rural areas where childbirth may involve travel over long distances. A positive finding of the survey was that almost all women living in the most remote health boards (NHS Highland and NHS Shetland) reported having received sufficient information to help them decide where to have their baby (90% and 89%, respectively).

2.18. The results suggest that women are not always being offered the opportunity to be involved in decisions about place of birth. Overall 41% of women reported being offered a choice of hospital for having their baby and 23% said that they were given the choice of giving birth in a midwife led unit or birth centre. However, 25% of women reported that they were not offered any choices of place of birth.

2.19. These results must be interpreted in relation to the maternity facilities available within NHS Boards. In some instances a woman's choice of hospital of birth would have required travel between NHS Board areas and this is likely to have influenced the offer of choice. For example, 66% of the women in NHS Lothian (two consultant units) were given a choice of hospital in which to have their baby, compared to 13% of the women in NHS Ayrshire and Arran (one consultant led unit and one island birth unit).

2.20. Similarly in NHS Tayside (one consultant led unit and three community midwife led units) 45% of the women reported being given a choice of giving birth in a midwife led unit/birth centre, whereas 4% of women in NHS Lanarkshire (one consultant led unit and no midwife led units) said that they were given this choice.

2.21. Only 25% of women reported that they were offered the choice of home birth and there was considerable variation between health boards (Table 10). In NHS Forth Valley 60% of women reported that they were offered the option of giving birth at home compared to 11% in NHS Greater Glasgow and Clyde. Overall only 2% of women reported that they planned to have a home birth; this is consistent with long standing low rates of home birth in Scotland.

Table 10: Choices of where to have your baby

Question: Did you get enough information from either a midwife or doctor to help you decide where to have your baby?
	Per cent	Frequency (n=1,654)	Confidence interval (%)
Yes, definitely	56	956	54.0	58.4
Yes, to some extent	26	419	24.0	28.0
No	18	279	16.1	19.5
Question: Were you offered any of the following choices about where to have your baby?
	Per cent	Frequency (n=2,346)	Confidence interval* (%)
A choice of hospitals	41	951	39.4	42.7
A choice of giving birth in a midwife led unit or birth centre	23	544	21.4	24.1
A choice of giving birth in a consultant led unit	12	281	10.7	13.0
A choice of giving birth at home	25	612	23.3	26.3
I was not offered any choices	25	582	23.7	26.8
I had no choices due to medical reasons	13	298	12.0	14.4
Question: Before your baby was born, did you plan to have a home birth?
	Per cent	Frequency (n=2,349)	Confidence interval (%)
Yes	2	59	1.5	2.3
No	98	2,290	97.7	98.5

2.22. In relation to involvement in decisions about their antenatal care more generally over three quarters of women felt that they were involved enough, while around one in five women either felt they were not, or were only sometimes, sufficiently involved (Table 11). There was little variation between NHS Boards.

Table 11: Were you involved in decisions about your antenatal care?

Question: Thinking about your antenatal care, were you involved enough in decisions about your care?
	Per cent	Frequency (n=2,339)	Confidence interval (%)
Yes, always	78	1,831	76.0	79.1
Yes, sometimes	18	407	16.6	19.4
No	4	79	2.9	4.3
I did not want / need to be involved	1	22	0.6	1.3

Communication

2.23. All staff involved in providing care to mothers and babies should communicate in ways that women can understand and ensure that they are listened to and have time to ask questions about their care.^6,16 Women were asked whether they were always spoken to in a way that they could understand, whether they were listened to and whether they were given time to ask questions or discuss their care.

2.24. The majority of women (88%) reported that they were always spoken to in a way that they could understand (with little health board variation) although 10% of women reported that this happened only sometimes (Table 12).

Table 12: Communication in antenatal care

Question: Thinking about your antenatal care, were you spoken to in way that you could understand?
	Per cent	Frequency (n=2,351)	Confidence interval (%)
Yes, always	88	2,085	87.2	89.5
Yes, sometimes	10	233	9.1	11.3
No	1	33	1.0	1.9

2.25. During their antenatal care, 82% of women said that they were always listened to and the same percentage said that they were always given enough time to ask questions and/or discuss their pregnancy (Table 13). Seventeen per cent of women said that they were listened to only sometimes and 16% said that they were only sometimes given enough time to discuss their pregnancy.

Table 13: Listened to and given enough time to ask questions?

Question: During your antenatal check-ups, were you listened to?
	Per cent	Frequency (n=2,348)	Confidence interval (%)
Yes, always	82	1,927	80.2	83.0
Yes, sometimes	17	386	15.4	18.1
No	2	35	1.1	2.1
Question: During your antenatal check-ups, were you given enough time to ask questions or discuss your pregnancy?
	Per cent	Frequency (n=2,357)	Confidence interval (%)
Yes, always	82	1,938	80.1	82.9
Yes, sometimes	16	365	14.8	17.5
No	2	54	1.8	2.8

Overall rating of antenatal care

2.26. Finally women were asked to rate overall the antenatal care they received while they were pregnant. Women generally rated their antenatal care highly. Ninety-one per cent of women reporting that their care was either excellent or good (Figure 2). Women in the island NHS Boards were most likely to say that they had received excellent care; NHS Orkney (77%), NHS Western Isles (76%) and NHS Shetland (74%).

Figure 2: Overall rating of antenatal care

Conclusions

2.27. Early access to maternity care is a key target for health improvement and is currently the only Scottish Government HEAT target relating to antenatal care. It appears to be being achieved overall but not consistently in every NHS Board. This may reflect the socio- economic variations in maternity populations with NHS Greater Glasgow and Clyde having the highest levels of socio-economic deprivation and less women booking by 12 weeks. The forthcoming variations report will provide more information on this issue.

2.28. Direct access to maternity care through the midwife as first point of professional contact for pregnant women was a key objective of the Scottish Government KCND programme⁸ and an associated Health Scotland campaign. However, across Scotland most women appear to visit their GP as first point of contact when they think they are pregnant although there was wide variation between health boards. The survey found that 58% of women first contacted a health professional by six weeks of pregnancy; this suggests that encouraging women to access maternity services directly by making their initial contact with a midwife may offer the opportunity for earlier antenatal booking. Self-diagnosis of pregnancy is already established practice and women should be encouraged and enabled to take further ownership of their care through self-referral directly to maternity services.

2.29. A very positive finding was that 99% of women had a telephone number to contact a midwife or midwifery team and 82% reported always receiving the help that they needed.

2.30. Continuity of care has been one of the long standing quality indicators for maternity care established in the 1993 report Provision of Maternity Services in Scotland²² and the Changing Childbirth Report 1993.²³ There is good research evidence that continuity of midwife led care can result in improved health outcomes for mothers and babies.¹⁸ The survey found wide variation between health boards. In some areas only 43% of women were receiving continuity of care while some were achieving over 70% of women who reported seeing the same midwife all or most of the time. This suggests that there may be opportunities for sharing good practice across health boards. Models of midwifery care that enable continuity of care should be supported in every health board.

2.31. Provision of information and involvement of women in choices and decisions about their care is also one of the long standing quality indicators for maternity care. Choice of place of birth is, to some extent, dependent on facilities available in health boards but even in health boards where all options were available less than half of women reported being offered a choice. Only around one quarter of women said that they were offered a choice of home birth and very few women ultimately opted for home birth. Offering women a choice of home birth is an explicit recommendation of the Scottish Government's Refreshed Framework for Maternity Care.⁶ However, there appears to be a mismatch between the policy recommendation, women's experience of being offered a choice and their uptake of that offer. Many factors will influence women's choices about where to give birth. However all women should receive unbiased information that explains the benefits as well as risks of giving birth at home, in a community midwife led unit and in a consultant led maternity unit.