Having a Baby in Scotland 2015: Maternity Care Survey

Chapter 2: Care During Pregnancy: Antenatal Care

Summary of key results

• 61% of women rated their antenatal care as excellent.
• 93% of women had their antenatal booking appointment by 12 weeks, 61% before 10 weeks.
• 99% of women had a number to contact their midwife or midwifery team, 84% who did so always got the help that they needed.
• 66% of women saw the same midwife all or most of the time for their antenatal checks, an increase from 2013.
• 15% of women saw a health visitor during their pregnancy and most said this was useful. 50% did not and said they did not want this.
• 20% of women were offered a choice of where their antenatal checks would take place.
• 24% were not offered any choice about place of birth and only 56% said that they definitely had enough information to help them make this choice.
• Over 80% of women said that they were listened to, had time to ask questions and were spoken to in a way that they could understand.
• Women's comments highlighted the importance of continuity of care and the opportunity to build relationships with their care providers. This was very important for women with more complex pregnancies involving the multi-professional team. Seeing different staff was tiring and frustrating for women and was associated with poorer communication and inconsistent information and advice.

Access to maternity care

2.1 Enabling women to make early, direct access to maternity care is a key target for maternity services (www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/AntenatalAccess). Scottish maternity policy and guidance encourages women to make self-referral directly to maternity services when they think that they are pregnant. The survey results show that a growing number of women contacted a midwife first when they thought that they were pregnant. The proportion of women who saw a GP first decreased to 50%, with an increase in the proportion who saw a midwife first (43%) compared to the findings of the 2013 survey (Table 5). Overall, 56% of mothers reported that they had first seen a health professional by 6 weeks of pregnancy and almost all had done so by 12 weeks. This is similar to the 2013 survey.

2.2 The survey findings indicate that women are completing their antenatal booking assessment earlier with more women reporting that they had their antenatal booking assessment by nine weeks compared to 2013. A majority of women (61%) reported that they had their antenatal booking assessment before 10 weeks of pregnancy and 93% had done so by 12 weeks. There was little variation by Health Board in the proportion of women who had their booking assessment by 12 weeks (between 90% in NHS Borders and NHS Fife, and 96% in NHS Ayrshire & Arran, NHS Grampian and NHS Tayside). However, women in NHS Ayrshire & Arran, NHS Grampian, NHS Highland and NHS Tayside were more likely to have an early assessment (at 9 weeks of pregnancy or less). The national HEAT target for access to antenatal care is for at least 80% of pregnant woman in each SIMD quintile to have booked for antenatal care by the 12th week of gestation by March 2015 (www.gov.scot/About/Performance/scotPerforms/partnerstories/NHSScotlandperformance/AntenatalAccess).

Table 5. Accessing maternity services in early pregnancy

Who was the first health professional you saw when you thought you were pregnant?
	2013		2015
	% (n=2,358)	Confidence Interval	% (n=2,031)	Confidence Interval
GP / family doctor	60	(58.5 , 61.8)	50	(48.5 , 52.4)
Midwife	35	(33.1 , 36.3)	43	(41.4 , 45.3)
Other	5	(4.3 , 5.9)	6	(5.2 , 7.2)
Roughly how many weeks pregnant were you when you first saw a health professional about your pregnancy care?
	2013		2015
	% (n=2,329)	Confidence Interval	% (n=2,010)	Confidence Interval
When I was 0 to 6 weeks pregnant	58	(56.3 , 59.8)	56	(54.3 , 58.3)
When I was 7 to 12 weeks pregnant	38	(36.2 , 39.7)	40	(38.5 , 42.5)
When I was 13 or more weeks pregnant	4	(3.3 , 4.8)	3	(2.5 , 3.9)
Roughly how many weeks pregnant were you when you had your booking appointment?
	2013		2015
	% (n=2,200)	Confidence Interval	% (n=1,908)	Confidence Interval
When I was 0 to 7 weeks pregnant	16	(14.3 , 17.0)	20	(18.8 , 22.1)
When I was 8 or 9 weeks pregnant	35	(33.2 , 36.6)	41	(38.5 , 42.6)
When I was 10 or 11 weeks pregnant	19	(17.3 , 20.2)	18	(16.4 , 19.7)
When I was 12 weeks pregnant	18	(16.3 , 19.1)	14	(12.3 , 15.2)
When I was 13 or more weeks pregnant	13	(11.9 , 14.4)	7	(6.1 , 8.3)

2.3 Almost all women (99%) said that they had a telephone number to contact a midwife or maternity care team if they needed to and most (84%) who used this number felt that they always received the help that they needed. However 16% said that they only sometimes or that they did not always receive the help that they needed (Table 6).

Table 6. Contacting maternity services during pregnancy

During your pregnancy, did you have a telephone number for a midwife or midwifery team that you could contact?
	2013		2015
	% (n=2,350)	Confidence Interval	% (n=2,027)	Confidence Interval
Yes	99	(98.7 , 99.4)	99	(98.3 , 99.2)
No	1	(0.6 , 1.3)	1	(0.8 , 1.7)
If you contacted a midwife or the midwifery team, were you given the help you needed?
	2013		2015
	% (n=1,922)	Confidence Interval	% (n=1,701)	Confidence Interval
Yes, always	82	(80.2 , 83.4)	84	(82.2 , 85.5)
Yes, sometimes	16	(14.3 , 17.4)	14	(12.5 , 15.7)
No	2	(1.7 , 2.9)	2	(1.4 , 2.7)

Who women saw for their antenatal care

2.4 Almost all women (98%) saw a midwife for their care with over a third (37%) also receiving care from a hospital doctor (Table 7). There is good evidence that models of midwifery care that include continuity of carer are associated with improved outcomes for mothers and babies^[5]. The importance of providing maternity services that facilitate the building of relationships between women and health professionals should not be underestimated. Several questions in this survey address these issues. The significance women place on continuity of care and relationships with maternity care staff is further reflected in the many additional comments made by women on this topic. Overall, 66% of women said that they saw the same midwife all or most of the time for their antenatal checks, an increase from 62% in 2013, however this means that one third of women did not experience continuity of carer. This varied quite considerably by Health Board, with 85% of women in NHS Grampian and 80% in NHS Ayrshire & Arran seeing the same midwife all or most of the time, compared to around 55% in NHS Fife, NHS Greater Glasgow & Clyde and NHS Highland. The survey found that 83% of women reported that they had a named midwife (this is a specifically named midwife who is responsible for co-ordinating and providing most of a woman's antenatal and postnatal care). Of these women, 63% saw that midwife all or most of the time, a further 31% saw them 'some of the time' and 7% said they had a named midwife that they did not see at all.

2.5 Scottish Government Early Years Policy (www.gov.scot/Publications/2015/10/9697) includes the principle that all children will have a Named Person available to them. The Named Person will be a consistent point of contact to provide advice and support for families who require it (www.gov.scot/Topics/People/Young-People/gettingitright/named-person). In many cases the named person for children from 0-5 will be the health visitor. Recognising the significant role of the health visitor in supporting families with children under five years old, a refreshed health visiting pathway has been introduced including health visitor contact with all women during the antenatal period (www.gov.scot/Publications/2015/10/9697). A new question in this year's survey asked women if they had had a discussion with a health visitor during their pregnancy. The recent introduction of this pathway is reflected in the finding that only 15% of women said that they had a discussion with their health visitor when they were pregnant (Table 7). Almost all of the women who had met with a health visitor said that their discussion was useful. However, 84% of women had not met with a health visitor during their pregnancy and while many said that they felt it would have been useful, over half said that they did not want to (Table 7). There may be a number of reasons for this; several studies have found that people often express a preference for the care that they have actually experienced^[6]. However, it may be that women require more information about the purpose and potential benefits of meeting with a health visitor during their pregnancy.

Table 7. Healthcare providers during antenatal care

Which of the following health professionals did you see for your antenatal check-ups?
	2013		2015
	% (n=2,358)	Confidence Interval	% (n=2,036)	Confidence Interval
Midwife	98	(97.3 , 98.4)	98	(97.3 , 98.4)
GP (family doctor)	12	(11.0 , 13.2)	8	(6.5 , 8.6)
Hospital doctor (e.g. a consultant)	37	(35.2 , 38.6)	37	(35.0 , 38.8)
Other	1	(0.9 , 1.7)	2	(1.4 , 2.6)
If you saw a midwife for your antenatal check-up, did you see the same one every time?
	2013		2015
	% (n=2,326)	Confidence Interval	% (n=2,007)	Confidence Interval
Yes, every time	20	(18.3 , 21.2)	21	(19.3 , 22.6)
Most of the time	42	(40.7 , 44.3)	46	(43.5 , 47.5)
No	38	(36.1 , 39.5)	34	(31.7 , 35.4)
Did you have a named midwife?
			2015
			% (n=1,933)	Confidence Interval
Yes, and I saw them all / most of the time			52	(49.9 , 53.9)
Yes , and I saw them some of the time			25	(23.6 , 27.1)
Yes, but I did not see them			5	(4.4 , 6.3)
No			17	(15.9 , 18.9)
During your pregnancy, did you have a discussion with a Health Visitor?
			2015
			% (n=1,891)	Confidence Interval
Yes, and it was useful			13	(12.0 , 14.8)
Yes, but it was not useful			2	(1.6 , 2.8)
No, but I would have found it useful			34	(32.2 , 36.2)
No, but I didn't want to			50	(48.1 , 52.3)

Information choice and involvement

2.6 The principle of enabling women to make choices about their maternity care has been central to maternity policy for over 25 years. The survey focussed questions on two specific aspects of choice; these were choice of location of antenatal check-ups and choice of place of birth. The results suggest that relatively few women currently feel that they have these choices. Overall 80% said that they had no choice about where their antenatal check-ups would take place (Table 8). Considering place of birth, just over half of women said that they were given enough information to help them decide where to have their baby. Only 36% were offered a choice of hospitals (a decrease from 41% in 2013), 25% were offered a choice of giving birth at home and almost one quarter of women said that they were not offered any choice. However, despite the evident lack of choices in these areas the large majority of women (81%) said that they had enough involvement in care decisions, a significant increase from 78% in 2013 (Table 9).

Table 8. Women's choices during antenatal care

During your pregnancy were you given a choice about where your antenatal check-ups would take place?
	2013		2015
	% (n=2,251)	Confidence Interval	% (n=1,950)	Confidence Interval
Yes	21	(19.2 , 22.1)	20	(18.0 , 21.3)
No	79	(77.9 , 80.8)	80	(78.7 , 82.0)
Before your baby was born, did you plan to have a home birth?
	2013		2015
	% (n=2,349)	Confidence Interval	% (n=2,025)	Confidence Interval
Yes	2	(1.5 , 2.3)	2	(1.7 , 2.6)
No	98	(97.7 , 98.5)	98	(97.4 , 98.3)
Did you get enough information from either a midwife or doctor to help you decide where to have your baby?
	2013		2015
	% (n=1,654)	Confidence Interval	% (n=1,354)	Confidence Interval
Yes, definitely	56	(54.0 , 58.4)	56	(53.1 , 58.3)
Yes, to some extent	26	(24.0 , 28.0)	27	(24.9 , 29.6)
No	18	(16.1 , 19.5)	17	(15.0 , 19.0)
Were you offered any of the following choices about where to have your baby?
	2013		2015
	% (n=2,346)	Confidence Interval	% (n=2,036)	Confidence Interval
A choice of hospitals	41	(39.4 , 42.7)	36	(34.5 , 38.2)
A choice of giving birth in a midwife led unit or birth centre	23	(21.4 , 24.1)	24	(22.3 , 25.4)
A choice of giving birth in a consultant led unit	12	(10.7 , 13.0)	12	(11.1 , 13.6)
A choice of giving birth at home	25	(23.3 , 26.3)	25	(23.2 , 26.5)
I was not offered any choices	25	(73.2 , 76.3)	24	(22.8 , 26.1)
I had no choices due to medical reasons	13	(12.0 , 14.4)	15	(13.1 , 15.9)

Table 9. Involvement in decision making during antenatal care

Thinking about your antenatal care, were you involved enough in decisions about your care?
	2013		2015
	% (n=2,339)	Confidence Interval	% (n=2,011)	Confidence Interval
Yes, always	78	(76.0 , 79.1)	81	(79.4 , 82.6)
Yes, sometimes	18	(16.6 , 19.4)	16	(14.5 , 17.5)
No	4	(2.9 , 4.3)	2	(1.7 , 3.0)
I did not want / need to be involved	1	(0.6 , 1.3)	1	(0.3 , 0.9)

Communication

2.7 Maternity care guidance emphasises that good communication between women and their healthcare providers is essential for safe, effective and person centred care www.healthcareimprovementscotland.org/our_work/reproductive,_maternal_child/programme_resources/keeping_childbirth_natural.aspx. Women need to have opportunities to raise concerns and to feel that these are listened to and taken seriously. Health care providers need to take the time to talk to women in ways that they can understand and to personalise the advice and care provided. The survey findings suggest that in general women feel that communication during their antenatal care was good (Table 10). Almost all (91%) said that they were spoken to in a way that they could understand. The large majority of women said that they were listened to and had time to ask questions, although almost one in five said that this happened only sometimes or not at all. Most women felt that their personal circumstances were taken into account during their antenatal care but 22% said that this was only to some extent or not at all (Table 11).

Table 10 Communication during antenatal care

During your antenatal check-ups, were you given enough time to ask questions or discuss your pregnancy?
	2013		2015
	% (n=2,357)	Confidence Interval	% (n=2,030)	Confidence Interval
Yes, always	82	(80.1 , 82.9)	82	(80.8 , 83.9)
Yes, sometimes	16	(14.8 , 17.5)	16	(14.2 , 17.2)
No	2	(1.8 , 2.8)	2	(1.3 , 2.5)
During your antenatal check-ups, were you listened to?
	2013		2015
	% (n=2,348)	Confidence Interval	% (n=2,021)	Confidence Interval
Yes, always	82	(80.2 , 83.0)	83	(81.3 , 84.4)
Yes, sometimes	17	(15.4 , 18.1)	16	(14.4 , 17.4)
No	2	(1.1 , 2.1)	1	(0.8 , 1.7)
Thinking about your antenatal care, were you spoken to in way that you could understand?
	2013		2015
	% (n=2,351)	Confidence Interval	% (n=2,027)	Confidence Interval
Yes, always	88	(87.2 , 89.5)	91	(90.0 , 92.3)
Yes, sometimes	10	(9.1 , 11.3)	8	(7.2 , 9.4)
No	1	(1.0 , 1.9)	1	(0.2 , 0.9)

Table 11. Personalised antenatal care

During your antenatal check-ups, were your personal circumstances taken into account?
	2015
	% (n=1,981)	Confidence Interval
Yes, definitely	78	(75.9 , 79.4)
Yes, to some extent	19	(17.7 , 21.0)
No	3	(2.3 , 3.7)

Overall rating of antenatal care

2.8 Women's overall rating of their antenatal care was high with 61% rating it as excellent and a further 31% rating it as good, results largely unchanged from the 2013 survey.

Chart 1 - Overall rating of Antenatal Care

What women said about their antenatal care

2.9 Women were asked 'Is there is anything else you would like to tell us about your antenatal care?' In total, 620 free text comments were returned representing around a quarter of the overall survey sample. The comments broadly related to, but were not restricted to the major themes in the questionnaire. The majority of comments focused on midwifery care, particularly continuity of care and the availability of midwives. There is some overlap between themes as women made connections for example, between lack of continuity and poorer communication and involvement.

Access to maternity care

2.10 Women appreciated being able to contact a midwife, to be offered reassurance, advice or when necessary, to have a check-up.

'Always felt I could contact them at any time. Very helpful and caring'.

'Throughout all my pregnancies, I have always had excellent care. Whenever I needed advice, there was always someone to help'.

2.11 Whilst the large majority of women were able to make contact with a midwife during their pregnancies when they needed to, a small minority of women experienced difficulty in contacting a midwife by telephone. For a few women, they felt that not having immediate access to a midwife by 'phone had a negative impact upon them.

'I found that I didn't get phoned back when I got the answering machine and had left a message which was frustrating, and on two occasions I actually had to go to the health centre to speak to someone solely because I had not been getting replies'.

Continuity of Care: Midwife Care

2.12 Many women highlighted continuity, or a lack of continuity, as a major factor in their experience of maternity care. The majority of comments suggest that by continuity women mean relationship continuity with a midwife. Women overwhelmingly identify having a relationship with a midwife throughout their pregnancy as positive, and report less happiness about seeing multiple professionals for their antenatal care. Having relationship continuity is reported by women as allowing them to build rapport and trust with a midwife, with whom they can talk freely. Continuity of care is further linked by a small number of women to better clinical outcomes for them and for their babies.

'Had a great midwife who put me at ease. I seen her every appointment so got to know her'.

2.13 Some women will experience several pregnancies and a number of comments indicated that continuity of midwife across pregnancies was particularly appreciated.

'Really fantastic and personal care as this was my next pregnancy following a first child who was still born. I had the same midwife for both pregnancies'.

2.14 There were a high number of negative comments on a lack of 'relationship continuity'. These focused on having to see multiple midwives during pregnancy, and finding this unhelpful, difficult, or just plain exhausting.

'I had a different midwife each time I had an appointment. It would have been nice to have the same one, to build a relationship like I did with my first pregnancy'.

'I saw so many different midwives which was so tiring'.

2.15 Several women felt that a lack of relationship continuity with a midwife led to inconsistency in the advice offered to them. Some women, who had been seen by numerous midwives during pregnancy, expressed the view that information was not passed on properly between them suggesting a lack of information continuity.

'Different midwives had different ideas, opinions or concerns'.

'Poor communication. Have to repeat things at every appointment. Things not written down. Notes went missing'.

Continuity of Care: 'Named Midwife'

2.16 A number of women were aware that they had a particular midwife assigned to their care, their 'named midwife'. In some settings a 'named midwife' approach was nominally being followed but was not then resulting in continuity of care in practice, leading to confusion and frustration for women.

'I was assigned to a named midwife in a clinic due to the location of my GP practice…I did not see my "named midwife" throughout any of my antenatal or postnatal care… I do not understand the benefits of having a named midwife when you never or rarely see them and are passed from pillar to post between midwives'.

Continuity of Care: Team Midwifery Care

2.17 For a minority of women who commented it was viewed as positive that they were able to get to know a whole team of midwives, or at least it was experienced as unproblematic that they were not offered relationship continuity with a midwife, but were instead provided with continuity of care through 'team-midwifery'

'It worked on a team system, so although I didn't see the same midwife every time, I saw one of four on the team and this team followed me up after birth as well, so you got to know them all'.

Continuity of Care: Consultant- led Care and the multi- professional team

2.18 It was not just continuity of midwifery care that was commented upon by respondents. Relationship continuity with a consultant was also an important issue for women who were under consultant-led care.

'When I became consultant led my pregnancy was no longer enjoyable… Once I started seeing the consultants it was difficult. I saw 4 different consultants. The first consultant answered all my questions and made me feel very confident, however the following 3 did not. They all had different ideas on how to treat me and how often and what bloods to test'.

2.19 Often it was this lack of consistency in approach that was reported by women as problematic in their consultant led care; with different doctors offering different opinions.

'Frustrating seeing different consultants every time. Each time I had to go through medical history and each consultant had different idea for on-going care. Very unsettling!'

2.20 Some women also highlighted a feeling of having 'missed out' on continuity of midwifery care or the experience of regular care from a midwife, as a result of needing to be under consultant led care where the pregnancy was high risk. However, other women highlighted good examples of multi-professional team working.

'I attended a combined clinic… and saw consultant, diabetic doctor and midwife … the care was exceptional and professional at all times'.

Person centred care, choice and involvement in decision making

2.21 Women appreciated care from hospital staff that was focused around their needs and this person-centred care was mentioned positively by a number of women.

'Hospital team extremely supportive when planning this birth and took previous bad birth experience into full consideration throughout'.

'I was consultant led, following a previous miscarriage. The level of care I received by my consultant and midwife was outstanding and hugely reassuring in my situation'.

2.22 A significant theme was the value of having individual experiences taken into account by health professionals, and being supported to deal with these. A number of comments suggest that a non-judgemental attitude is a valued attribute in a midwife.

'I had extremely difficult circumstances during my pregnancy. The midwives I seen never judged me on these and helped me to sort out the situation and I was so grateful to them'.

2.23 Less positively, several women commented that their partners had felt excluded from discussions and decision making about the birth when meeting with hospital midwives and consultants and expressed the view that care should be more 'family-centred'.

'This was a stressful time in our lives and we had to make some important decisions together. It would have helped if the midwives had a more 'family approach' at this stage, especially when they see mums valuing/choosing that type of approach themselves'.

Choice of place of birth

2.24 A number of women expressed that they had less choice of where to give birth than they would have liked. Some acknowledge either with acceptance or regret that due to their location or their circumstances their choice of where and how to deliver their babies was necessarily limited. Other women commented specifically on choices in how they received their antenatal care in terms of where and when their antenatal appointments would take place. A number of women reported dissatisfaction with the convenience of their antenatal care, due to having to travel or being expected to miss work to attend appointments.

'I wish I was given the option of another hospital'.

'I feel I could have been told about more my choices for birth, as I was not told about any other ways, other than in a hospital'.

2.25 And a small number of comments suggest that women did not have sufficient information to make an informed choice about where to birth their babies.

'Would have been useful to have a leaflet outlining the options for places to give birth with the pain relief options available at each and explicitly stating what would not be available e.g. at birth centre compared to normal labour ward'.

2.26 A number of women made comments concerning the limited options they had about medical procedures during the pregnancy, the type of delivery they would have, and the pain relief they would use in labour.

'I never got the chance to say what birth I wanted. They told me I was getting a section and I wanted a normal birth!'

2.27 Some women had received information but felt it was unbalanced or designed to point them in particular direction.

'I was given a choice of hospitals where I could give birth, however, I did feel there was some pressure to birth at the local community unit. I chose to birth at a larger, city unit where there was more medical support'.

'I lost confidence / trust in my midwife after she pressured me, using reasons like "we don't carry resuscitation equipment" into a hospital birth and requested someone else'.

Trust and confidence in staff

2.28 Women highlighted their positive experiences of midwives being friendly, approachable, caring, supportive, and listening to and responding to any concerns and expressed satisfaction where midwives had taken time with them and made it possible to voice concerns.

'My antenatal appointments were excellent… The midwife that I saw most frequently… couldn't have been friendlier and ensured I knew my baby and I were her utmost priority. Couldn't praise her highly enough!'

'The midwife was excellent and listened to all my concerns as well as supported me through them. I also had access to hospital care when other health issues arose'.

2.29 However, there were some instances where midwives are described as having been condescending, patronising, dismissive, or rushed.

'I had very poor experiences with a midwife… She was short with me, did not fully explain answers to questions I had, and I felt she was always in a rush. She missed an appointment she made with me and acted like my concerns were irrelevant'.

2.30 Understaffing or overbooking in clinics resulting in long waiting times is highlighted as an issue by high numbers of women. The perceived pressure on midwives to see a high volume of women in their clinics lead some women to the feeling of having been 'just a number' or that their appointments followed a checklist with little time for genuine engagement or to raise questions and worries.

'I felt that my appointments were rushed (with community midwife). They were ok but I felt like "just a number"'.

Antenatal Classes and preparedness

2.31 A number of women thought to comment on their antenatal classes. The timing, availability or otherwise, and content of these classes are all were discussed. Some respondents indicated that they had found the classes helpful.

'Having antenatal classes helped me feel more prepared for birth and motherhood. It also helped me find mum friends, who have helped me before and after birth'.

2.32 Others were disappointed that their classes had been cancelled, rearranged, or had not been accessible to them, sometimes due to the pre-term arrival of their babies.

2.33 The idea that preparation for breastfeeding could be experienced as pressure to breastfeed can be read in the 'free text' data, along with the view that breastfeeding preparation tends to be unrealistic and 'rose tinted' in its approach.

'Lots of pressure to breastfeed from day 1. I do, but would have felt bad if couldn't'.