A Refreshed Framework for Maternity Care in Scotland: The Maternity Services Action Group

Accountability and planning mechanisms are in place to ensure that the delivery of maternity care is reflective of national policy and guidance.

Mechanisms are developed at NHS Board / regional level to integrate maternity care into all relevant service planning structures.

NHS Boards work towards having robust integrated data collection mechanisms in place to ensure epidemiological and demographic data is used to plan services.

NHS Boards have a named Executive Director for maternity services who makes annual reports via agreed governance mechanisms.

NHS Boards plan and provide fully integrated neonatal and maternity care responsive to the needs of their population.

NHS Boards have evidence that they carry out Equality Impact Assessments of their maternity care strategies.

NHS Boards ensure that maternity care is effectively integrated to local children and adult service planning mechanisms.

NHS Boards ensure that they effectively include maternity care planning and provision within community planning partnership processes.

NHS Boards have evidence that they consider maternity care as part of their workforce planning processes.

NHS Boards have evidence that their primary care strategies encompass maternity care and that primary care services are effectively involved in the planning and delivery of maternity care.

Maternity care is delivered by appropriately trained and skilled staff ²⁶ able to deliver person centred, safe and effective care.

Integrated service / workforce / financial planning mechanisms are in place and responsive to changing epidemiology and demographics in the population.

Workforce planning takes account of current and predicted workforce demographic profiles.

Workforce planning of skill mix enables the delivery of person centred, safe and effective services.

NHS Boards have evidence that they have effective integrated mechanisms in place to plan their workforce education and development in a way that reflects their population's needs.

NHS Boards have evidence that future education and training needs are informed by appropriate processes including workforce training needs analysis.

NHS Boards have evidence of workforce uptake, (including primary care contractors) of training and development resources that are aligned with the priorities for maternity care services.

Data collated at local and national levels is of relevance and utility to clinicians, service planners performance managers and the Scottish Government.

There is a dynamic approach and processes in place to ensure that data capture and presentation is relevant and meets current needs, including equality impact assessment requirements.

Any gaps in data sets/ information at national and local levels is identified and action taken.

Maternity care services have efficient and effective systems in place for data collection and analysis.

Maternity care services ensure that all women are provided with and encouraged to use the Scottish Women Handheld Maternity Record.

NHS Boards have evidence that maternity care services are complying with all maternity data return requirements.

NHS Boards have evidence that all women have a standardised Scottish Woman Held Maternity record ( SWHMR).

NHS Boards ensure that the systems they use are able to effectively and efficiently capture all of the SWHMR fields.

NHS Boards have evidence that their IT systems comply with nationally identified data requirements and that information is returned to ISD within specified timescales.

NHS Boards have evidence that they are exchanging information and data with Primary Care, with appropriate patient consent, for service planning purposes.

All women have early direct access to and uptake of safe and effective maternity care.

Systems are in place to ensure that all women are offered the option of attending a midwife as the first professional contact, ensuring women are also aware that the choice of seeing their GP at any point in their pregnancy is available.

Antenatal care services are tailored and proportionate to local population need.

Inequalities in access to maternity services are identified and effectively addressed.

Antenatal care services are promoted through all appropriate NHS and local authority services including-sexual and reproductive health services, mental health services, community addiction services, specialist mental health services, social services etc.

NHS Boards have evidence that they are tailoring reach to women and babies known to be at risk of poorer outcomes. ²⁷

NHS Boards have evidence that maternity care services audit uptake of antenatal services prioritising measurable improvements in uptake by women at risk of poorer outcomes.

NHS Boards have evidence that they are working with their Community Planning Partners, including the Third sector to improve access to maternity services- prioritising early access and sustained engagement with maternity services amongst those women and their babies at risk of poorer maternal and infant health outcomes.

NHS Boards have evidence that there are effective communication and collaboration between maternity services and primary care services, with specific processes where these services are not colocated.

NHS Boards have evidence that there is effective liaison, communication and pathways between maternity services, primary care, public health nursing and other NHS services working with women at risk of poorer outcomes.

Early intervention, prevention and promotion of maternal and infant health and well being are integral elements within maternity care planning and provision.

Relevant national pathways, guidelines and models are implemented.

Relevant advice and guidance from professional bodies and statutory organisations is implemented.

A Health Plan Indicator for level of health service support needed during pregnancy and after the baby is born, can and should be identified at any point during the antenatal period.

NHS Boards have evidence that maternity care services are integrated to local children's services planning and vulnerable adult planning mechanisms.

NHS Boards have evidence that maternity care services have processes in place to monitor adherence to and implementation of appropriate national pathways, guidelines and models of care.

NHS Boards have evidence that maternity care staff have processes in place to ensure that statutory and professional body advice is followed.

NHS Boards have evidence that maternity care staff have the training, development and support they need, including regular supervision.

Continuous quality improvement processes and outcome measures are in place within maternity services to ensure the safety and wellbeing of women and their babies.

Scottish Patient Safety Programme tools are routinely utilised.

All maternity staff have a clear understanding of the concept of risk assessment and management.

Patient communication and language support systems are effectively employed.

Adverse incidents/near misses information is routinely collated and used for individual and team development.

A mechanism for effective team development and communication is in place.

Maternity care staff have a clear understanding of the importance of social risk- for example domestic abuse, child protection concerns etc.

Evidence of robust clinical governance and multi-disciplinary risk management systems which report to the NHS Board.

NHS Boards have evidence that maternity services are utilising national risk management tools.

NHS Board's have evidence that they are utilising Maternity Service Dashboards in accordance with Professional Body Guidance.

NHS Boards have evidence of robust clinical and professional leadership for maternity services across all levels within the organisation.

NHS Boards have evidence of implementation of robust clinical and statutory midwifery supervision.

NHS Boards have evidence that appraisal processes are in place for the systematic and multi-disciplinary dissemination and sharing of learning from adverse events and near misses.

NHS Boards have evidence that effective induction and ongoing learning processes are in place for all maternity services staff.

NHS Boards have evidence that they monitor their trends in near misses and adverse events and have action plans in place in response.

NHS Boards have evidence that they have proactive plans in place to reduce healthcare acquired infection rates during pregnancy.

Communication and information provided to women in relation to their maternity care has the following key features:

• Enables women to make informed decisions about their care,
• Is clear, consistent, balanced and accurate, and based on the current evidence,
• Is supported by written information and/or available in different formats,
• Is presented in a way that all women can understand (including women with additional needs such as sensory (visual, hearing) or learning difficulties; women who do not speak or read English and women with poor health literacy.

Information and communication tools are used in a way that is responsive to individual women's needs.

Information is available in a variety of formats and is regularly updated.

Maternity care staff ascertain that women understand the information, care and advice they receive.

NHS Boards have evidence that communication, language, translation and advocacy resources in place and that these are being utilised by all services providing maternity care.

NHS Boards have evidence that maternity care staff have the training, development and support they need to effectively meet women's communication and information needs.

NHS Boards have evidence that women's experience of the quality of communication and information during their journey through maternity care is gathered and used for continuous service improvement purposes, prioritising improvements in groups at risk of poorer health outcomes.

NHS Boards have evidence that maternity care services regularly review the quality of the information they provide to women and their families.

NHS Boards have evidence of collaborative working between maternity services, public health nursing primary care services and other services in contact women during the maternity period.

Public involvement in maternity care services planning, and women and their families experience of maternity care, is proactively and routinely sought and utilised to improve services.

Patient experience feedback tools and Patient and Public Involvement processes are integral to maternity care service improvement.

Maternity care staff are actively supported to deliver person centred care through effective learning and development and supervision processes.

Maternity care services utilise the Scottish Health Council's 'Good Practice in service user involvement in maternity services'

NHS Boards have evidence that maternity care is influenced by women's experience and public involvement feedback.

NHS Boards have evidence that maternity care services take account of relevant national and local service user surveys.

NHS Boards have evidence that maternity care services have taken all reasonable steps to secure appropriate user involvement representative of their local population within their maternity services liaison committees.

NHS Boards have evidence that they are measuring improvements in the experiences of women at risk of poorer health outcomes.

NHS Boards have evidence that there is provision and uptake of learning and development opportunities for staff to deliver person centred care.

Maternity care services enable and promote active research, implementation and evaluation cycles which directly improve health outcomes for women and their babies.

Local audit activity influences practice.

Maternity care services work effectively with their local and national research and development departments.

Maternity care services enable wider regional and national research collaboration.

NHS Boards have evidence that local audit cycles are improving clinical practice.

NHS Boards have evidence that there is investment in research and development activity that relates to maternity services.

Maternity care services recognise the role of a woman's partner and the baby's father and/or other social networks, making sure they are involved in supporting the woman during pregnancy in line with the woman's wishes.

Women's partners or significant others are included in the provision of antenatal education programmes, care and birth planning processes.

Maternity care staff provide all women with access to private time in line with national guidance recognising that not all women are in supportive relationships.

NHS Boards have evidence that fathers, partners/family/friend involvement is encouraged and occurs in accordance with the woman's wishes.

NHS Boards have evidence that all women are offered private time with a midwife or with the GP (where women opt to see their GP instead of the midwife) to discuss partner involvement.

Specific pre conception services are available to women who need them ( e.g. poor obstetric or medical history, previous poor fetal or obstetric outcomes, or where there is a family history of significant illness or disease).

A local / regional approach is taken to the planning and provision of specific services as appropriate.

Primary care services utilise their disease registers to offer opportunistic and targeted pre-conceptual services.

NHS Boards have evidence of a specific pre-conception service for women based on appropriate guidance, pathways and models.

NHS Boards have evidence that they are utilising data from primary care to plan preconception services

NHS Boards have evidence that staff, including primary care contractors have the necessary training, development and support required to undertake their role.

All women who experience complications in early pregnancy have access to an early pregnancy assessment service.

All Health professionals across the NHS system are aware of the service and able to refer directly to it.

Women who experience early pregnancy complications are cared for in a dedicated area distinct from the general gynaecology or obstetric ward.

Women who miscarry are offered a choice of management options.

NHS Boards have evidence that information about their early pregnancy service is effectively communicated to women and maternity care services.

NHS Boards have evidence that maternity care services have formal referral arrangements in place, including the option for women with previous problems to self refer.

NHS Boards have evidence that there is access to ultrasound facilities in secondary and tertiary units.

NHS Boards have evidence that staff have the training, development and support they require to effectively support bereaved women, their partners and families.

All women have early and timely access to appropriate, safe and effective antenatal care.

Antenatal care is delivered in line with national guidelines, pathways and models.

All women have an initial assessment of their health, obstetric and social needs completed and are offered appropriate screening referral and care options by twelve weeks gestation.

There is ongoing assessment of wellbeing at every ante-natal contact.

Antenatal care and support is tailored and proportionate to individual need.

As far as possible services are provided in locations and at times that meet the needs of local populations.

NHS Boards have evidence that maternity services are improving uptake of antenatal services, including antenatal education, ensuring uptake by women at risk of poorer maternal and infant health outcomes. ²⁸

NHS Boards have evidence that maternity care services are assessing maternal health and social need by twelve weeks gestation prioritising assessment of women at risk of poorer maternal and infant outcomes.

NHS Boards have evidence that they are collecting and utilising domestic abuse data in line with national guidance.

NHS Boards have evidence that multi-professional and multi-agency working practices, pathways and models are in place for the care and support of women and their unborn babies, and these are improving maternal and infant health outcomes.

NHS Boards have evidence that maternity care services gather and utilise women's experience of accessing antenatal care - prioritising women with poorer maternal and infant health outcomes.

NHS Boards have evidence that staff have the training, development and support they need to effectively assess a woman and her unborn baby's health and social needs.

An evidence based, tailored and proportionate health improvement programme is provided by maternity care services throughout the antenatal period.

The national syllabus for antenatal education is implemented.

The Maternal and Infant nutrition framework action plan is driving practice.

Every antenatal contact is seen as an opportunity for health assets/strengths based health promotion

Maternity staff work in partnership with women in relation to their health and well being prioritising

• Smoking cessation in pregnancy
• Maternal and infant nutrition- including the promotion of breast feeding and the management of maternal weight
• Drug/substance misuse and alcohol use in pregnancy
• Maternal and infant mental health and well-being
• Oral health improvement
• Contraception

Appropriate information and promotional materials; DVDs etc. are available to meet individual women's needs- including women with poor health literacy.

Maternity staff work in partnership

with local services including the Third sector.

NHS Boards have evidence that maternity services are tailoring health improvement programmes for individual women and their babies prioritising those at risk of poor maternal and infant health outcomes.

NHS Boards have evidence that maternity services have appropriate programmes in place to promote abstinence from alcohol in pregnancy and are measuring the impact of these programmes on alcohol use in pregnancy.

NHS Boards have evidence that maternity services are increasing referrals to smoking cessation services and that smoking cessation rates in pregnancy are increasing.

NHS Boards have evidence that they are implementing the maternal and infant nutrition strategy and are measuring impact on women and infants.

NHS Boards have evidence that maternity services are effectively promoting increased uptake of Healthy Start benefits and financial inclusion approaches such as income maximisation, financial capability support and money and debt advice services.

NHS Boards have evidence that maternity services are providing parenting education and support and measuring uptake and benefit of impact of this.

NHS Boards have evidence that maternity service staff have the necessary training, development and support to improve health using the health asset models.

NHS Boards have evidence that maternity care staff gave knowledge and understanding of the impact of social inequalities on maternal and infant health.

A high quality antenatal screening, diagnostic and follow up service is available and offered to all women in line with national guidance.

All women are offered appropriate screening options as early as possible - ideally by ten weeks

National information resources are used effectively

All women receive the information and the opportunities for discussion that they need to make informed decisions about taking up screening options

NHS Boards have evidence that the proportion of down's syndrome screening undertaken in first trimester for all women is increasing and they are taking action to improve where necessary.

The proportion of mothers having antenatal sickle cell and Thalassaemia screening that have a conclusive screening result by 10 weeks' gestation is increasing.

NHS Boards have evidence that screening and diagnostic services are offering all women appropriate information to allow informed choice, including tailored information for those who are known to come from groups who have poorer health outcomes.

NHS Boards have evidence that they are using effective approaches and working with national and local partners to promote awareness of screening and diagnostic services.

NHS Boards have evidence that screening staff have the necessary training, development and support to provide safe and effective screening and diagnostic services.

NHS Boards have evidence that appropriate referral protocols are in place following screening and ensure all women receive appropriate follow up.

NHS Boards submit data for the national KPIs for pregnancy screening.

A lead professional is identified for all women for antenatal care.

All women have a named midwife allocated who can provide continuity of carer during the antenatal period.

A midwife is the lead professional for all low risk women and is responsible for the planning and provision of antenatal care, with support from wider maternity care services as required.

An obstetrician is the lead professional for women with complex needs, supported by midwives and other maternity care staff.

Lead professionals liaise with the multi professional team as required, including the woman's GP; ensuring women are encouraged to access their GP and others as appropriate.

Midwives and GPs have complementary roles in the care of pregnant women and work collaboratively and effectively together.

A public health nurse will be the named person and/or the lead professional for the baby's plan in the antenatal period depending on the level and nature of support required

NHS Boards have evidence that they are gathering women's experience of care and using this for continuous service improvement.

NHS Boards have evidence that maternity services are ensuring that staff record the required information accurately.

NHS Boards have evidence that they are actively measuring the impact of a named midwife and lead professional on improved maternal and infant health outcomes.

The choice of where and how to give birth should be reached using a process of decision making where the clinician and the woman are partners in ensuring the woman and baby are as safe as possible.

Maternity services ensure that women are given appropriate, accessible and evidence informed information and are fully involved in the decision making process.

Protocols are in place for the safe transfer of mothers and babies to and between services

NHS Boards have evidence that Communication translation, and Language plans are in place and utilised within maternity services

NHS Boards have evidence that they are gathering and using women's experience of the process involved in the choice of place and method of birth.

NHS Boards have evidence that maternity services ensure that all required information relating to the birth is recorded and transferred to the national data set and exchanged with Primary care with the appropriate patient consent.

NHS Boards have evidence that maternity services have effective risk assessments processes in place for the safe delivery of mothers and babies and are monitoring maternal and infant health outcomes.

NHS Boards have evidence that maternity care staff have the necessary training, development and support required.

Maternity services provide a fully integrated person centred, high quality childbirth service that is safe and effective.

All women have 1:1 care by a midwife when in established labour.

A midwife is the lead professional for women

Women in established labour have a named midwife to provide one to one care on a shift to shift basis.

Access to consultant obstetrician and anaesthetic services is available as required in line with national guidelines.

Maternity staff working in theatre, recovery and high dependency units are trained in line with national and statutory body guidance.

Standards of care for women requiring theatre services, recovery and high dependency care adhere to national and statutory body guidance.

Clear pathways are in place for referring mothers between units and to intensive care services.

A named lead professional with considerable theatre experience has the responsibility for the safe management of obstetric theatres on a day to day basis and ensures that the required standards of safe effective theatre care are met.

Women should be assessed on presenting for care and in labour and offered an appropriate birth care pathways, avoiding unnecessary intervention, regardless of the birth setting.

Women should be continually assessed and offered care in line with national guidelines.

The planned choice of birth made by the woman in the antenatal period should be provided where possible; ensuring the safety of the woman and her baby is of primary importance.

Women are offered a choice of pain relief- management appropriate to the setting in which they choose to give birth.

Women who have epidural analgesia or an operative delivery, have their pain assessed using a pain assessment tool.

Maternity services are critically appraising Caesarean section rates, including regional and general anaesthetic rates.

Maternity services critically appraise all unexpected admissions to Intensive care Units.

Appropriate pathways and protocols are in place for transfer of mother and / or baby where necessary.

NHS Boards have evidence that maternity services ensure that information is able to be captured in the identified data set.

NHS Boards have evidence that labour units have robust clinical governance and risk management processes in place leading to reduced incidence of near misses and adverse clinical events.

NHS Boards have evidence that maternity services have effective processes in place for the systematic and multi-disciplinary dissemination and sharing of learning from adverse events and near misses.

NHS Boards have evidence that there are critical appraisal processes for CS rates in place including effective action plans to address any upward trends and ensure clinical adherence to national guidelines.

NHS Boards have evidence that epidural analgesia is available at all times in consultant led units.

NHS Boards have evidence that they are gathering women's experience of pain relief during birth and using this information to drive continuous service improvement.

NHS Boards have evidence that maternity service staff have the necessary training, development and support required.

All women and their babies are provided with person centred, safe and effective postnatal care.

Postnatal care is delivered in line with national guidelines, pathways and models.

All women and babies have an assessment of their health and social needs completed and are offered appropriate screening, referral and postnatal care options.

There is ongoing assessment of the mother and baby's need at every postnatal contact.

Postnatal care and support is tailored and proportionate to the needs of the mother and baby.

Robust and effective communication and liaison processes are in place between maternity teams, primary care staff, public health nurses and local authority services.

NHS Boards have evidence that maternity care services are taking steps to continuously improve postnatal services for all women ensuring tailored, proportionate care for women and babies at risk of poorer outcomes.

NHS Boards have evidence that maternity care services are assessing maternal and infant health and social needs for all women , prioritising care management for women and babies at risk of poorer maternal and infant outcomes.

NHS Boards have evidence that maternity care services gather and utilise women's experience of postnatal care - ensuring women with poorer maternal and infant health outcomes experience is gathered.

NHS Boards have evidence that staff, including primary care staff, providing postnatal care have the training, development and support they need to effectively assess and respond to a woman and her baby's health and social needs during the postnatal period.

A high quality postnatal screening, service is available and offered to all women and their babies in line with national guidance.

All women are offered appropriate screening for their infants in line with the newborn screening programme

National resources are used effectively to provide information to women

All women are offered appropriate screening in line with national pathways, guidelines

All women receive accessible, relevant information and have the opportunity for discussion in relation to the screening programme

NHS Boards have evidence that they are monitoring uptake of their screening services for women and their babies

NHS Boards have evidence that screening services are monitoring and improving uptake of their services amongst all women and those who are known to come from groups who have poorer uptake rates.

NHS Boards have evidence that they have referral pathways in place to ensure appropriate follow up.

NHS Boards submit data for the national KPIs for newborn screening.

A named professional and where necessary a lead professional is identified for all women and babies during postnatal care.

All women have a named midwife allocated who can provide continuity of postnatal care for a minimum of 10 days post birth.

Lead professionals liaise with the multi professional team as required, including the woman's GP; ensuring women are encouraged to access their GP and others as appropriate.

A public health nurse will be the named person and/or the lead professional for any child's plan in the postnatal period depending on the level and nature of support required.

NHS Boards have evidence that postnatal care is based on multi-professional and multi-agency working practices.

NHS Boards have evidence that pathways and models are in place for the safe and effective care and support of women and their babies in the postnatal period.

NHS Boards have evidence that they have the necessary mechanisms in place for safe and effective communication and collaboration between maternity services, Primary Care services, Public health nursing services and other services.

NHS Boards have evidence that they are regularly auditing postnatal care outcomes for women and babies.

NHS Boards have evidence that they are gathering women's experience of care in the post natal period and are using this for continuous service improvement.

An evidence based, tailored and proportionate health improvement programme is provided by maternity care services throughout the postnatal period

Maternity care staff work in partnership with women in relation to their own and their baby's health and well being. Essential areas depending on individual circumstances are:

• the impact of smoking or passive smoking on the babies wellbeing
• Maternal and infant nutrition- in line with the maternal and infant nutrition framework
• Drug/substance misuse and alcohol use and care of the baby
• Maternal and infant mental health and well-being- ensuring support services are in place if necessary
• The importance of oral health
• Prevention of accidents to infants in the home.

Staff promote the use of longer acting reversible methods of contraception and where appropriate, and provide contraception before discharge from postnatal care particularly to more vulnerable women e.g. teenage mothers, women with substance misuse problems and sex workers.

Staff provide information and advice on contraception; family spacing and women are directed to appropriate providers of contraceptive services.

NHS Boards have evidence that they are providing tailored proportionate health improvement information and support to parents in the postnatal period

NHS Boards have evidence that they are implementing and measuring the impact of the infant and maternal nutrition action plan.

NHS Boards have evidence that maternity units and Community Health Partnerships are working towards and/or achieving UNICEF accreditation.

NHS Boards have evidence that they are critically appraising their breast feeding rates and have planned improvement measures in place particularly for those women in need of additional encouragement and support.

NHS Boards have evidence that women are provided with information relating to contraception, sexual health and relationships, and where appropriate provided with contraception, particularly long acting, reversible contraception.

NHS Boards have evidence that they are gathering women's experience of health improvement support in the postnatal period and using the information to drive continuous service improvement.

Postnatal discharge planning processes and mechanisms are person centred, safe and effective.

Managed Clinical Networks for neonatal care are in place.

National pathways, guidelines and models underpin practice including Child Protection and domestic abuse protocols and duties.

Relevant advice and guidance from professional bodies and statutory organisations underpin practice.

Robust and effective communication and liaison mechanisms are in place between maternity services staff, primary care teams, public health nurses and local authority services.

The lead professional in the postnatal period will be identified in line with the health and social care needs of the woman and baby

Mechanisms are in place for a safe and effective transition from midwifery to public health nursing and primary care services

NHS Boards have evidence that integrated discharge planning processes and pathways of care are in place across specialist maternity, neonatal, primary care, public health nursing services and other specialist services such as addictions, mental health services and sexual health services.

NHS Boards have evidence that maternity care services, children's services and adult services have joint planning processes in place-in addition to critical care planning.

NHS Boards have evidence that maternity care services have processes in place to ensure that statutory and professional body advice is followed by all staff in relation to postnatal and newborn care.

NHS Boards have evidence that maternity services provide staff with the necessary training, development and support including regular supervision to ensure the safe and effective discharge of women and their babies from maternity care.

NHS Boards have evidence that they are gathering women's experience of integrated discharge planning processed in the postnatal period and are using the information to drive continuous service improvement.