Moray Maternity Services Review: report

5 Considering Proposed Models of Service Delivery

As described above, the Review Group has been tasked with describing the best model for service delivery in Moray that will provide safe, deliverable, sustainable and high quality maternity services for the women and families of Moray.

An initial long list of models was considered, which included two models – Model 1 and Model 2 – both of which were ruled out at an early stage.

5.1 Model 1: The Status Quo

The current 'As Is' model includes intrapartum care provided through a community maternity unit, with "Life and Limb" support from consultant obstetricians.

To retain the status quo, with services to continue as they are at present, was excluded from consideration by the Review Group, because, although there is no evidence of adverse outcomes for women, both Professor Cameron in his report and the Review Group believe there are potential risks to patient safety. The service is not considered or perceived to be safe by the wider community. Neither does it have support from women and their families, members of staff, nor the other stakeholders with whom the Review Group engaged.

In this 'As Is' model, it is unclear at present as to which women can safely give birth in Dr Gray's. As a result, this model of service provision has lost credibility as a suitable maternity service.

5.2 Model 2: No Intrapartum Services in Moray

Under this model, no intrapartum care would be provided in Dr Gray's, with women in Moray (except those who choose to have a home birth) giving birth in either Aberdeen or Raigmore.

Whilst this model was included for completeness, it was not considered a viable or appropriate model, and was, therefore, immediately excluded. It was acknowledged by the Review Group that adopting this model would greatly reduce options for women and their families, and remove the choice of giving birth locally for nearly all women in Moray. As such, this would not be in line with 'Best Start' principles, nor would it meet the needs of families.

The Review Group then considered four further potential models for the delivery of maternity services in Moray:

5.3 Model 3: Community Maternity Unit* linked mainly to Aberdeen

• Women are offered a choice of intrapartum care at either Dr Gray's, Aberdeen or Raigmore, with the associated antenatal care provided at Dr Gray's (as appropriate, based on the complexity of their care requirements).
• Midwife-led and consultant-supported antenatal care in Dr Gray's (potentially provided by visiting consultants from Raigmore and/or Aberdeen).
• Limited midwife-led antenatal triage and day assessment.
• Midwife-led intrapartum care, offering the potential to provide approximately 20% of Moray births (all of these births will be "low risk").
• No obstetric medical cover for intrapartum care; and therefore, no facility for obstetric interventions, such as instrumental deliveries and emergency caesarean sections.
• Main link for higher risk pregnancies and intrapartum transfers to Aberdeen, as currently, with a small proportion to Raigmore. Around 80% of Moray birth's delivering outside Moray.

5.4 Model 4: Community Maternity Unit* linked mainly to Raigmore ("Moray Networked Model")

• Women are offered a choice of intrapartum care at either Dr Gray's, Aberdeen or Raigmore, with the associated antenatal care provided at Dr Gray's (as appropriate, based on the complexity of their care requirements).
• Midwife-led and consultant-supported antenatal care in Dr Gray's.
• Midwife-led antenatal triage and day assessment expanded to 24-hour availability.
• Midwife-led intrapartum care in Dr Gray's, offering the potential to provide approximately 20% of Moray births (all of these births would be 'low risk').
• No obstetric medical cover for Dr Gray's intrapartum care; and therefore, no facility for obstetric interventions, such as instrumental deliveries and emergency caesarean sections.
• Access to planned consultant-led intrapartum care shared between Raigmore and Aberdeen as part of a 'network'; with the choice of unit dependent upon a clinical risk assessment, the woman's personal choice, and geographical location.
• Consultant-provided elective caesarean sections in Dr Gray's (offering the potential to increase the number of births by a further 20%); caesarean section service expected to be provided by consultant gynaecology staffing, and supported by the existing theatre and anaesthetic teams. This will also require flexibility of midwife staffing to provide a 24/7 staffed unit as required.
• In the event of emergency or urgent transfers, women will be transferred (by ambulance) to Raigmore, unless they are clinically required to transfer to the specialist unit in Aberdeen.

5.5 Model 5: Rural Consultant-supported Maternity Unit*

• Midwife-led and consultant-supported antenatal services in Dr Gray's.
• Midwife-led and consultant-supported intrapartum care in Dr Gray's, with the service offered to women who have been carefully risk-assessed and selected. There is potential to provide care for between 50%-70% of Moray women (based on the Scottish Northern Isles' approach).
• Obstetric medical cover available in Dr Gray's on a 24/7 basis (on-call from home out of hours). This model, based on risk assessment, includes provision for Obstetric interventions, including instrumental births and emergency caesarean sections in Dr Gray's.
• Elective caesarean section service in Dr Gray's for selected women provided by consultant obstetrician gynaecologists and supported by the Anaesthetic and Theatre teams.
• Links for planned consultant-supported intrapartum care for higher risk births shared between Raigmore and Aberdeen as part of a "Network"; with the choice of unit dependent upon a clinical risk assessment, the woman's choice and geographical location.
• In the unlikely event of emergency or urgent transfers, women will be transferred to Raigmore, unless specifically clinically required to transfer to the specialist unit in Aberdeen.

*this unit to be located in Dr Gray's Hospital in Elgin

5.6 Model 6: Consultant–led Maternity Unit^[11]

• Consultant-led unit with alongside maternity unit operating from Dr Gray's, with the wrap-around support necessary to sustain an extended maternity service.
• This would include all antenatal, intrapartum and postnatal services.
• This would offer the women of Moray the choice to give birth in Dr Gray's with a very small number of women who may still require, in the interests of the wellbeing of the mother and baby, to give birth, in the tertiary obstetric unit in Aberdeen.

*this unit to be located in Dr Gray's Hospital in Elgin