Having a Baby in Scotland 2015: Maternity Care Survey

Chapter 5: Discussion

5.1 This is the second in the series of Scottish maternity care experience surveys following the first such survey undertaken in 2013 and using essentially the same questionnaire allowing for comparison of results. The survey was sent to a sample of women who gave birth in Scotland during February and March 2015, following reminders a total of 2,036 women returned questionnaires giving a response rate of 41%, down slightly from the 48% response rate obtained in 2013. The survey was large and random sampling and analysis based on number of annual births in each NHS Board has ensured that the survey is as representative as possible of the range of maternity care experiences in Scotland. However, women who responded tended to be in the older age groups and younger women are somewhat underrepresented in the survey.

5.2 This report presents the national level findings and for the first time this includes a full analysis of the additional 'free text' comments made by women who responded to the option 'If there is anything else you would like to tell us about your care …. please do so'. Overall 1,244 women made comments equating to just over 61% of the total sample providing a total of 2,667 comments distributed between antenatal care, care during labour and birth and postnatal care.

5.3 Service user experience surveys and in particular maternity care experience surveys are sometimes criticised with the suggestion that those who respond tend to provide disproportionately positive responses. It is widely acknowledged that women may have a tendency to rate their maternity care positively^[11],[12] and this potential for positive bias must be taken into consideration when interpreting the survey results. As with the 2013 survey the majority of responses to all questions were positive and the overall rating of care for each time point was high, in particular for antenatal care and care during labour and birth. However, the inclusion of the qualitative comments in this report considerably adds to the understanding of the questionnaire results. In this survey the use of four free text boxes at the end of each section invited women to comment specifically on that particular aspect of their care thus focussing women's comments, and to some extent, reducing the wide ranging nature of comments reported by some surveys^[3]. However, there may be some bias in these comments and this must be considered. For example, it may be that women who had more negative experiences felt moved to describe them, where for women with positive experiences the tick box options on the questionnaire were sufficient. This may explain why the main survey results are in general very positive while the comments tend to be more negative. The report aims to maintain a balance in reporting the comments, many of which are quite emotive. Nevertheless a large number of women chose to make comments on their experiences of care and these provide valuable insights into maternity care in Scotland in 2015.

5.4 As in the 2013 survey this survey reports overall a very positive picture of women's experience of maternity care. Indeed there are only a very few differences in the findings from 2013. However, there are some important areas where the results, together with the qualitative findings, suggest that women's experiences of care and indeed other aspects of care quality could be improved. It is through celebrating the many examples of excellent practice and examining areas where care appears to have fallen short that lessons may be learned and the overall quality of care improved.

5.5 The survey suggests that women are accessing maternity services early in their pregnancy with over half making contact with a health care professional by six weeks and over 90% having their antenatal booking appointment by 12 weeks. Women increasingly appear to be contacting a midwife first when they think they are pregnant although the majority still access maternity care via their family doctor. For both antenatal and postnatal care almost all women appear to have a number to contact the midwifery team if they require to do so, and most who do report receiving the assistance that they require. The clear exception to this is women's experience of contacting maternity services when they think that they may be in labour. Women are generally advised to contact their maternity hospital or birth unit by telephone when they think that their labour has started. The questionnaire asked one question about whether women felt that they received appropriate advice and support when they contacted a midwife or the hospital. The large majority of women said that they did, however a considerable number of women commented on their very negative experiences of contacting their maternity unit, triage area or other first point of contact when they thought labour had started. Many women appear to have encountered staff who were dismissive or patronising and who did not appear to take them seriously, this contrasted strongly with women's generally very positive accounts of the supportive care they received when they were admitted to the labour ward or birth unit. There is a considerable body of research indicating how uncertain and vulnerable women and their families feel at this time.^[10] While maternity guidance suggests that healthy pregnant women should remain at home until labour has established, many women require reassurance and supportive care at this time, these women may benefit from a more women centred approach.

5.6 Almost all women receive midwifery care throughout their pregnancy, birth and postnatal care, with considerable involvement of the multi-professional care team. Around 67% of women said that they saw the same midwife all or most of the time through their antenatal care (a small increase from 2013), with less (51%) saying that they saw the same midwife all or most of the time for their postnatal care at home. The large number of comments on this topic both relating to antenatal and postnatal care indicates the importance to women of having the opportunity to develop relationships with the staff who provide their care. Many women commented on the importance of continuity of care across the multi professional care team, this was particularly important for women who were experiencing more complex pregnancies. Women clearly associated continuity of care with good communication and the development of a supportive and trusting relationship. Where their experience of continuity of care was poor women described the wearisome process of having to repeatedly explain their circumstances to a series of different staff. Some women felt that they were falling through the gaps rather than receiving a seamless service. There is robust evidence for the benefits of continuity of carer. Models of midwifery care involving continuity have been associated with important clinical and psychosocial benefits including reduced preterm birth and fetal loss before 24 weeks, increased rates of normal birth and greater satisfaction with care.^[5] This evidence along with the survey findings indicates that continuity of carer is an essential element of safe, effective and women centred care.

5.7 The survey findings indicate that in general communication between women and maternity care staff was good. At most time points women report being spoken to in ways that they could understand, being listened to and having time to ask questions. Women clearly valued supportive and non- judgemental attitudes in staff who cared for them. Women tended to report that they were sufficiently involved in decisions about their care, although this was not always the case during labour and birth. However, in relation to the specific aspects of choice included in the questionnaire, location of antenatal and postnatal check-ups and about place of birth, relatively few women appear to have been offered choices. While, as noted in the 2013 report, choice of place of birth may to some extent be limited by facilities available in different locations, the principle of offering women a choice of place of birth and home birth is a long standing aspect of maternity care policy in Scotland. Offering women a choice of where their antenatal check-ups take place may be more straightforward, as a range of local facilities are more likely to be available, however few women said that they had this choice. Similarly few women were offered a choice of location for their community based postnatal care. Relatively few women received postnatal check-ups in a clinic reflecting the situation where traditionally postnatal midwifery care has been provided in the woman's home. This may change as maternity services seek to adopt different models of postnatal care. Changing the pattern and % of postnatal community care may be appropriate as not all mothers and babies will require the same level of care; for some mothers a clinic visit may be the most convenient option however, as the survey findings indicate that for many mothers in particular for those recovering from a caesarean birth or for those without transport, it may be difficult to get to a clinic with a new baby.

5.8 Labour and birth have long been considered to be a time of increased vulnerability for mothers and their babies and it is therefore noteworthy the very high level of confidence and trust that women appear to have in the maternity staff who cared for them at this time. Care during labour and birth was rated more highly than at other time points with 93% of women reporting that their care was either excellent or good.

5.9 A considerable number of women commented to express the trust that they had in staff including members of the multi-professional team, and expressed how this had enhanced their birth experience. However, there were some areas where women's experience of care and support during labour and birth could be improved. A small but significant minority of women said that they were left alone when it concerned them; while in most instances this was in the early stages of labour, some women said that this was during or shortly after birth. A noteworthy finding was that a substantial minority of women did not feel that they received sufficient help to cope with their pain during labour and birth. In addition, as with the findings of the 2013 survey, although a majority of women said that they were able to move around and choose comfortable positions during labour, a considerable number of women appear to give birth in a supine position (flat on their back) with 16% of women who had a normal birth saying that they gave birth with their legs in stirrups. Few women commented on this however there is good evidence that more upright positions facilitate normal birth and these should be encouraged where possible.

5.10 Overall, the comments suggest that access to skilled staff throughout labour, the support of their birth partners and receiving sufficient pain relief were aspects of care that were of considerable importance to women. Maternity care policy in Scotland has long recommended that all women in established labour should receive one to one midwifery care and there is good evidence for the benefits of this.^[9] A study conducted in Scotland of midwifery care in labour^[13] found that high quality care involved midwives providing almost continuous emotional support (being attentive, encouraging, coaching, comforting), while at the same time giving physical support i.e. massage, helping the woman move into comfortable positions, providing fluids and nutrition, advising, informing and listening, leaving women alone for only short periods of time.

5.11 Postnatal care both in hospital and at home were rated less highly than either antenatal or intrapartum care. With findings very similar to those reported in 2013 a significant minority of women did not feel that they always received the information and advice that they needed and that advice, in particular relating to infant feeding was often inconsistent. Around one third of women said that they were not always treated with kindness and understanding. Asked about care in the six weeks following birth, just over half of women felt that they had enough information about their own physical recovery or potential emotional changes, despite the longstanding body of research that has consistently indicated that many women experience long term physical and mental health problems following childbirth, and that they often do not actively seek medical advice or assistance^[14],[15].

5.12 The 'free text' comments provide a valuable indication of what good care consists of for women in the immediate post-natal period, as well as detailed description of the ways that it can fall short, providing insight into why only just over half of women felt able to give their care in hospital an 'excellent' rating. Women's comments indicated that they appreciated compassionate and sensitive care in this period, and a hospital environment which afforded them and their babies' sufficient access to clinical care, food, rest and support. They reported disappointment with over-stretched staff teams, lack of care and attention, being left alone and separated from the support of family, and care which did not meet their physical and emotional needs in the immediate aftermath of the birth. Once women went home they valued the on-going support of midwives and health visitors but were often frustrated by inconsistent advice when many different staff were involved in their care.

5.13 The length of time women remain in hospital after giving birth has declined steadily in recent years, although this does not appear to have changed significantly since the 2013 survey. At the same time more women with complex health problems are becoming pregnant and the caesarean section rate is rising (to 30% in some areas www.isdscotland.org/Health-Topics/Maternity-and-Births/Births/). This means that there is a high throughput of mothers and babies in the hospital postnatal wards with much of the midwives time taken up by the high intensity admission and discharge procedures leaving staff with little time to undertake the more supportive aspects of care, advice and practical assistance for mothers during their very short 'recovery phase' in hospital.^[16] The Royal College of Midwives report that staff workload is high and stressful^[17] and it is clear from the comments made by women that this can have a negative impact on women's experience of care.

5.14 The Scottish Government policy framework that aims to ensure all children have the best possible start in life and that Scotland will be the best place in the world to grow up www.gov.scot/Topics/People/Young-People is committed to transformational change in relation to improvements in early year's health and wellbeing. If this change is to succeed it is imperative to recognise that the early years start with conception and that many children may be already disadvantaged by the time they are born. High quality, safe effective and person centred maternity care from early pregnancy (or even pre-pregnancy) through labour and birth and the first weeks following birth is essential if mothers, babies and families are to thrive and achieve their full potential. This national survey report highlights many areas of excellent practice where policy and practice guidance are being achieved. It also highlights areas where improvements could be made. Listening to the voices of mothers and drawing on their individual and collective experiences provides invaluable insights and inspiration for further improvement in Scotland's maternity services.