NHS Grampian

Maternity Strategy

DRAFT March 2007

This strategy is available in large print and on computer disk. Other formats and languages can be supplied on request. Please contact NHS Grampian Corporate Communications Team on 01224 554400 for details.

CONTENTS

Summary

  1. Background
  2. Progress to Date
  3. Preconception and Early Pregnancy
  4. Public Health and Maternity Services
  5. Pregnancy and Newborn Screening
  6. Assessing and Managing Risk
  7. Training and Education
  8. Public Involvement
  9. Workforce Planning
  10. Neonatal Care
  11. Environment of Care
  12. Recommendations summary

Appendix 1Maternity Service Profile

Appendix 2Policy Documents and Papers

Appendix 3A Framework for Maternity Services in Scotland

Appendix 4 Antenatal Care in Grampian Guidelines 2007

Maternity Strategy for Grampian - 2007

Summary

NHS Grampian has a long history of providing maternity care for women in a range of settings with access to a team of health care professionals according to the needs of the woman and her baby. At times changes to the service become inevitable in response to new clinical evidence about the way care should be delivered, movements in where the population reside, changes in the health of women having babies, changes to the numbers of staff available to deliver this care and changes to services which link in with maternity care. The underpinning principles in providing Maternity Care is similar to all other care in that it should be provided by staff who are suitably prepared for the roles they perform, that the service is managed effectively and efficiently and that the service itself is sustainable.

These issues have led to the production of a NHS Grampian Maternity Strategy which looks at all of these influences in the context of enabling women and their families to have the best possible experiences and outcomes from their involvement with the Maternity Services in Grampian. This will be achieved by reviewing the services that exist and confirming they are fit for purpose, looking at any gaps that exist and prioritising the work required to ensure the service remains dynamic, effective and efficient.

We know from evidence that generally healthy woman have healthy babies and this strategy aims to ensure that women are encouraged and supported to improve their health before, through and after pregnancy. The strategy is centred on women and their families and also demonstrates the values and needs of the professionals who provide the care. Initial data for 2006 indicates that in 2006, 5,800 live babies were born in Grampian. In addition a significant number had miscarriages and a small number (30) had stillborn babies. Approximately 850 babies require admission to a Neonatal Unit for care management.

NHS Grampian considers that good communication between women and those caring for them and their babies is central to the provision of excellent maternity care. This communication and the written information which reinforces it play a vital part in ensuring that women feel part of any decisions necessary about their care and in enabling choices about the care content. This is a fundamental principle which runs through the strategy.

The strategy looks at the “pregnancy year“, reflecting the fact that good health prior to pregnancy is highly desirable and in the control of the majority of women.The post natal period is a time of physical and emotional adjustment which can be influenced by factors which occur throughout the pregnancy episode. Support in the post natal period is important to establish good physical and emotional health. An integrated care pathway approach is and the strategy will address this.

It is important that the service analyses its performance in a structured way. Clinical risk management activity is essential for the services to reflect on comments, complaints and clinical incidents that occur. A programme of clinical audit provides evidence of measuring outcomes and compliance with best practice statementsThe Strategy reinforces this activity and ensures that there are strong links with NHS Grampian Clinical Governance processes.

Ensuring that staff are educated and trained well to deliver the care in all settings where the service is delivered, is a fundamental principle in any care setting. The strategy describes what is in place and encourages some initiatives to ensure that the education issues are being anticipated and addressed appropriately.

Emerging issues in Maternity Services include a growth in the number of women with special needs, be that physical disability, mental ill health, non English speakers, substance misusers or the very young. Multi disciplinary and multi agency working is essential in these cases and additional time is often required to ensure the best possible outcome for mother and baby. The strategy recommends approaches which may assist in tackling these issues.

Public involvement in planning and delivering changes in services are crucial to ensure that the changes are understood and acceptable to service users. NHS Grampian gives commitment to establishing effective Liaison Committees, the number depending on the location of services. At present we await the outcome of the Ministerial Action Group to inform a way ahead but we are committed to making progress in this area.

Finally NHS Grampian is committed to supporting the national work towards promoting normality in maternity services. The strategy demonstrates the initiatives in Grampian which will enable activity around this.

RECOMMENDATION SUMMARY

  1. Governance

TheMaternity Services Clinical Management Board should lead Maternity Services in Grampian by active participation of all sectors so that key changes are discussed and debated and by communicating more widely with the stakeholders.

The Birth Unit concept in Aberdeenshire CHP should be evaluated over a time frame to be agreed. There should be no expansion of this concept until that evaluation has taken place.

  1. Activity

The impact of changing demographics and ethnicity for the Maternity Services is not yet clear and more intelligence must be gathered around this to ensure health needs are known and addressed as appropriate.

3.Pre-Pregnancy Care

As well as the general activity provided by health promotion services, more targeted activity should be designed to reach women who are planning pregnancy so that they are in the optimum health from the outset.

Health promotion activity in the education (school) sector requires regular liaison with NHS maternity care providers locally to maximise the potential of targeting pupils at the most appropriate times.

Women requesting pre pregnancy advice should be able to access an appropriate health professional including the midwife on an individual basis.

Community Pharmacists should be encouraged to maximise opportunities to participate in pre pregnancy preparation. Provision of health education, folic acid with pregnancy testing kits and smoking cessation support are examples of this.

4.Public Health - Smoking

Smoking cessation interventions must be offered to every pregnant woman who smokes and the most appropriate arrangements made for each individual woman

Training and educational opportunities must be made available to key professionals who care for pregnant women, in particular Community Midwives who deliver the majority of a woman’s care.

Robust evaluation of outcomes must be available to inform progress and measure success.

5.Public Health – Domestic Abuse

Women should be asked about Domestic Abuse routinely at some point in pregnancy which may be dependant on when a midwife can see the woman on her own.

Midwives and others in the Pregnancy Team should have access to awareness and routine enquiry training to ensure appropriate skills exist to manage any disclosure which occurs.

The Maternity Services in Grampian should undertake an audit of disclosure to assess the effects of routine enquiry.

6.Perinatal Mental Health

Recent progress should be maintained in all aspects of the service.

Appropriate education and training programmes for key staff including midwives, health visitors and community psychiatric nurses should be a priority for the newly appointed Specialist Nurse. This can be a graduated approach including awareness sessions on mental health and mental illness, more detailed education for those conducting assessments and providing on going support and specialist education for a small number who wish to reach that level of expertise.

7.Substance Misuse

Continue to monitor the service to ensure that it is meeting need.

Continue to develop the expertise of the wider professional community so that skills expand in local settings.

Assess the impact on Neonatal Unit and consider alternative ways of delivering care minimising the need for separating mother and baby.

Consider how alcohol misuse may be impacting on Maternity Service and pregnancy outcomes.

  1. Child Protection

Ensure that Child Protection remains at the forefront throughout the pregnancy episode by providing regular awareness training for all staff.

Continue to provide more specific training for case load holders and those contributing to Child Protection Case Conferences.

9.Neonatal Care

Continue to build expertise in modern neonatal care management and reflect this in care management.

Develop and utilise the expertise of the wider team in delivering routine care for neonates to maximise availability of cots in Neonatal Unit.

Continue to support the service in Dr Gray’s Elgin, the Regional Neonatal Transport Service and the Neonatal Resuscitation Programme.

Continue to work closely with Combined Child Health Service.

10.Risk Management

Continue to develop Risk management activity by involving as many care providers as possible. This should include active involvement of Supervisors of Midwives.

The outcomes of critical incident reviews must be reflected in service improvement and education and training whenever indicated.

Continue to develop written information for women which contains the best available evidence presented in non technical terms and make this available at appropriate times during the pregnancy.

11.Education and Training

Continue to develop relevant education events to meet the diverse needs of the care professionals and monitor their appropriateness.

Continue to work collaboratively with education providers as demonstrated by the joint programme for Maternity Care Assistants with RGU and Assisted Birth Practitioners with the University of Bradford.

Continue to develop staff according to service need as well as professional desires to ensure that the demands of a dynamic service are being met.

12.Public Involvement

Take steps to establish effective Maternity Services Liaison Committee(s) accessible for women across Grampian.

13.Workforce Planning

As far as possible prepare plans to meet the demands of Modernising Medical Careers and Working Time Directives for medical staff in all services.

NHS Grampian should continue to explore workforce modelling with accredited tools for midwifery and neonatal care so that there is evidence to support workforce resource requirement and allowing benchmarking across Health Boards.

New roles should continue to be developed and be service driven and supported by New Roles Framework document, ensuring that education and training are anticipated, planned and delivered before the roles are implemented.

Further work should be undertaken to explore the potential for regional working and maximising potential for e Health systems.

Ensure that any developments in workforce are assessed financially to confirm that service remains affordable and sustainable.

14.Care Environment

Consideration must be given to the replacement of AberdeenMaternityHospital, including Neonatal Unit with a modern purpose built facility, linked to main services in Aberdeen Royal Infirmary.

1. Background

It is recognised that for the vast majority of women, pregnancy is not an illness but is a major life experience with significant social and psychological impacts on the woman and her family. However in addition some women and babies do require specialist care and it is incumbent on NHS Grampian to ensure that the entire service is provided to the required standard. A service description is provided in Appendix 1.

The model of care in Grampian is designed to ensure that each woman receives care tailored to her individual needs. Systematic reviews of trials for low-risk women have shown that routine antenatal care for low-risk woman in community settings by GPs and midwives appears as clinically effective as obstetrician-led shared care, and is highly acceptable to women. Reviews also indicate that reduced schedules of routine visits could be implemented without jeopardising safety for mothers or babies. The model includes:

  • Woman-centred care according to personal needs
  • Locally accessible and community-based care with access to a specialist as needed.
  • Fewer but systematic visits to improve consistency, continuity and reduce duplication
  • Joint working supported between primary, secondary and tertiary services

This means that if all is well obstetrically and medically and the woman chooses, her care is carried out in the community by midwives and GPs with easy referral to Obstetricians if a complication develops. However if the complication resolves the care is transferred back to community care.

Positive experiences and outcomes of care can be facilitated by adhering to the principles contained in A Framework for Maternity Services in Scotland (2001) and the subsequent Expert Group Report on Acute Maternity Services in Scotland (EGAMS 2003). These principles are as relevant in 2007 as they were at the outset.

These principles

  • Support partnership between women, their families and the professionals providing care
  • Celebrate pregnancy and childbirth as normal physiological events in a woman’s life
  • Seek to improve the standard of care by challenging professionals to meet the needs of women and their families
  • Promote care delivered in the most appropriate setting by well trained and educated staff using risk assessment techniques to aid clinical decision making
  • Promote a Regional approach to service planning and delivery wherever appropriate

These principles form a template for maternity care throughout Grampian whilst considering their local application in a range of geographical settings in a mixed urban and rural environment. They are underpinned by professional best practice statements, clinical guidelines, health reports, national and local perinatal morbidity and mortality statistics, and considerboth clinical and staff governance as well as public expectation and involvement.

The multidisciplinaryteam is tailored to the needs of individual women and their babies and includes midwives, General Practitioners, Obstetricians, Anaesthetists, Allied Health Professionals, Neonatologists and Neonatal Nurses, Community Psychiatric Nurses, Health Visitors, social workers and other experts as required.

Effective Maternity Services are dependant on this group of Health Professionals to be appropriately trained and educated to deliver the best possible care. There are close links with the two local Universities, the RobertGordonUniversity who provides pre and post registration programmes for midwives, nurses and professions allied to health and AberdeenUniversity who provides programmes for medical staff. As important are locally provided practical skills seminars and courses where issues can be analysed in a pragmatic way by the team of staff who deliver the care in that setting

Influences on the content and organisation of Maternity Care come from a variety of sources including professional organisations such as the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Anaesthetists, the British Association of Perinatal Medicine, the Nursing and Midwifery Council (NMC),and National Institute for Clinical Evidence (NICE). NHS Quality Improvement Scotland (QIS) set standards for care the most notable being the Maternity Standards which were inspected in April 2006 and the Clinical Standards for Anaesthesia which were inspected in mid 2005. The next standard to be inspected relates to Pregnancy and Newborn Screening which is planned for late 2007 (date to be confirmed). Maternity Services also participate in national reviews through the Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH) which produces various publications on audits of maternal morbidity and mortality. On a UK wide basis the service participates in Confidential Enquiries into Maternal and Child Deaths which reports every 3 years.

Maternity Services are also subject to national Health Department planning and directives the most pertinent being the report produced by Professor David Kerr in 2005 which set out a national framework for service change in NHS Scotland. Whist Maternity Services were not emphasised in this report many services which support Maternity Services have to address the recommendations. Messages from the change agenda are that care must be effective, efficient and sustainable. It should be delivered in the most appropriate setting depending on its complexity and available expertise to deliver the care safely. For some services that will mean a move from large hospital based care to more local care, for others the move will be to centralise care in the big centres. For maternity services the model of care will remain women focussed and midwife led, delivered locally as far as possible with access to expert services as and when needed.

To further assess the impact of modernising the NHS on Maternity servicesa Ministerial Action Group has been established to look at aspects of the serviceincluding a Neonatal Service Review, the promotion of normality, a review of Liaison Committees, and aspects of transport in particular in remote areas. The outcomes of this review can not be included in this strategy but attempts will be made to anticipate recommendations where appropriate.

Workforce planning is fundamental to how Maternity Services can be delivered in the future. Changes to the way medical staff are trained (Modernising Medical Careers) is already impacting on junior medical staff in all specialties, Working Time Directives impose limits on the hours of work for all staff groups and more flexible working patterns can limit the availability of staff in some areas. This is being addressed at local and regional level using manpower modelling tools for example in Neonatal Nursing and Birthrate Plus for midwives. This is already leading to the emergence of new roles such as Maternity Care Assistants, Assisted Birth Practitioners and Advanced Neonatal Nurse Practitioners who will enable care to be provided in a different way, supported by robust education preparation.