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

7. Overall Conclusions and Recommendations

7.1. The results of the first National Survey of Women's Experiences of Maternity Care in Scotland for over 15 years provide a valuable insight into maternity care in Scotland in 2013. The findings provide a benchmark that will be used at local health board and national government levels to target healthcare improvements and inform future maternity policy directions.

7.2. Women who gave birth in Scotland during February and March 2013 returned questionnaires; the response rate of 48% is comparable to that obtained by the concurrent maternity care survey undertaken in England. Although this represents a relatively small sample of women who gave birth in Scotland during 2013 the survey method used a random sampling approach stratified by health board size and the questionnaires and reminders were sent directly to women's homes, this gives us some confidence that the findings are likely to be somewhat representative of the overall experiences of women giving birth in Scotland in 2013.

7.3. Although the survey is likely to represent the views of the 'average' woman, some groups were under represented in the survey results for example, younger women and women from some ethnic minority groups. Other groups of women were deliberately excluded altogether; women who experienced the loss of their baby were not sent a questionnaire as it contained several sections that were not appropriate for them. Most similar surveys use the same approach; however, it is imperative that the views and experiences of women who have experienced the loss of their baby are sought. The Scottish Government Refreshed Framework for Maternity Care in Scotland highlights the importance of seeking the views of all groups of maternity service users. Further work is required to develop appropriate survey and other methods tailored to the needs of this important group of women and their families as well as those of other groups of women who are less likely to respond to large scale surveys.

7.4. Further analysis of survey findings will now be conducted to produce a variations report to describe the experiences of specific groups of women who responded to the questionnaire. This report will identify differences in the maternity care experiences of groups such as first time mothers, mothers from lower socio-economic groups or mothers from rural communities and will provide further insights into some of the issues highlighted in this report. For example, this report has identified that women do not always feel that they have been given the advice and support for infant feeding, however it is not yet clear whether this applies more to specific groups such as first time mothers or to mothers who have chosen to breast feed their babies. This secondary analysis will provide information to inform more specific areas of need for service improvements.

7.5. The survey has highlighted many areas of good practice and examples where the aspirations and recommendations of maternity care policy are being achieved. Overall the survey findings indicate that at each stage of the maternity care journey the majority of women's experiences of maternity care are positive. At each stage a majority of women rated their care as excellent. This was particularly the case for women's care during labour and birth where 73% of women rated their care as excellent. However, it is recognised that women may reluctant to express negative views of the care they have received.^{14, 24} and this potential for positive bias must be taken into consideration when interpreting the survey results. Women's experiences of key aspects of care provide important information about any differences between care as it is intended and care as it is received. While the survey found women's experiences were in general very positive, important lessons may be learned by focusing on the more negative experiences reported by a significant minority of women.^{14, 24, 25} With this in mind the report highlights a number of areas where care may be improved and where there are wide variations in women's experience between NHS Boards. Some of these are long standing issues which seem resistant to change despite considerable 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 now be required, such as working with women, families and communities to co-design services and solutions to improve women's experience of maternity care.

Key points

7.6. 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 which are in line with other data sources on antenatal access 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. 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.

7.7. 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.

7.8. The majority of women said that they had trust and confidence in the staff caring for them during their labour and birth. However, over 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.

7.9. Over one quarter 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 deliver also gave birth while lying flat, some 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; and these findings suggest that this remains an area with potential for continued improvement.

7.10. 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 more women said that they only sometimes received the information and advice 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.

7.11. 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.

7.12. 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 carer for both antenatal and post natal care. Within Scotland there are examples of health boards in which higher than average continuity of care is being achieved and this 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 the 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.