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A Framework for maternity services in Scotland

Introduction

Purpose and Scope of the Framework

Improvements have been made to maternity care provision following the 1993 Policy Review, Maternity Services in Scotland. These include a range of choices around childbirth, the provision of high quality local services that are acceptable and accessible to women with speedy and seamless access to specialist services when necessary.

But there is still considerable scope for further change that reflects a modern maternity service appropriate for the 21st Century. The following broad themes are important:

• safety and evidence-based care for mother and baby must remain the foundation of an effective maternity service;
• pregnancy and childbirth are normal physiological processes in women's lives;
• maternity services must deliver a woman and family-centred approach to care and support planned in partnership with the woman;
• maternity services should be essentially community based and midwife managed, wherever possible, with an emphasis on continuity of care.

The Framework has been informed by the 1993 Policy Review, the audit report "Maternity Care Matters" (1999) and other relevant documents and available evidence related to maternity care, see Bibliography. All of these, without exception, call for fundamental changes in the structure and culture of maternity services to better reflect the needs of women today, their children and their families.

This Framework has been developed in consultation with women, professionals and consumer organisations involved in providing maternity services.

This Framework has been developed for women, professionals and service planners and providers. It is not a strategy document or a model service specification. It is a philosophical approach that outlines a set of broad principles to inform local maternity services strategies.

It sets out the clear local action required so that NHS Boards, NHS Trusts and other agencies can make sure that maternity services are appropriate to the needs of the people and geography of Scotland. It recognises that there are specific issues that impact on service provision in remote and rural areas.

The Framework will also be a benchmark for the Scottish Executive to assess implementation of local strategies and action plans, and monitor progress.

The Framework recognises that:

• social influences before, during and after pregnancy have a significant and far-reaching impact on child and maternal health;
• social investment in the next generation is the key to healthy families and healthy people, and will help to make a healthier future for everyone;
• government cross-cutting policies are targeting resources to the 30% of Scottish children born into relative poverty in key areas such as childcare, education, employment, health, housing and welfare benefits;
• pregnancy is an ideal opportunity to involve women, their partners and their families in a far greater understanding of their personal health, the benefits of health promotion and changes that can affect future health;
• education for a healthy pregnancy should start in school, and life skills and lifestyles should be a core part of personal and social development.

This Framework covers the main elements of maternity care: preconception, pregnancy, childbirth and postnatal/parenthood. It:

• recognises that pregnancy is the beginning of the process of life-long parenthood;
• offers a vision for a modern, essentially community based maternity service which meets women's needs before, during and after pregnancy;
• calls for an integrated woman-centred, multi-disciplinary/multi-agency approach to developing maternity services.

The Framework sets out principles for service organisation and provision. Service requirements must drive the workforce requirements.

There are real tensions between numbers of available professionals, the current training programmes, the implications of the EC Working Time Directive and the delivery of a safe service. But, as the Scottish Integrated Worforce Planning Group has made clear in its interim report, planning the workforce for the future must take account of models of service delivery, including multi-disciplinary teams, and the model used must be appropriate to the local situation.

Detailed work is needed to set out the workforce implications of the service principles in this Framework. The Scottish Executive Health Department, through the Scottish Integrated Workforce Planning Group, will specify and commission a piece of work with the aim of defining suitable maternity workforce models by the end of 2001. In the meantime, NHS Boards and NHS Trusts should apply the Workforce Planning principles set out in Appendix 6 of this Framework to inform local service organisation. These will also be used to inform the proposed work outlined above.

A large Multi-Professional and Expert Reference Group was set up to inform and develop this Framework.

Remit of the reference group and sub-groups

The Reference Group was chaired by Miss Anne Jarvie, Scotland's Chief Nursing Officer, and included invited representatives from the key professional groups and consumers with an interest in maternity services. It was set up to encourage wide participation and views. Details of the Group's membership and remit are set out in Appendix 1.

The Reference Group set up 5 sub-groups. These were chaired by members of the Reference Group, had Reference Group representation within them as well as other invited professionals and interested parties. The sub-groups were as follows:

• Remote and Rural;
• Education, Training and Workforce Planning;
• Pattern of Services;
• Best Practice including Professional Roles;
• Public Health, Lifestyle and Maternity Care.

The work of the Reference Group and the sub-groups was informed by Scotland-wide consultation with women and health professionals.

Consultation with women and professionals

The Reference Group identified a number of themes, such as informed choice and homely environment, and models of care that had consistently emerged from the review of available literature. These themes were addressed by the Group and sub-groups, and also by the Scotland-wide Focus Group consultation involving women and professionals.

It was important that the Framework was informed by a clear women's perspective. Scottish Health Feedback, an independent research organisation, was invited, through the Scottish Association of Health Councils, to complete qualitative research that would allow the views of service users across Scotland to be collated through Focus Groups and one-to-one interviews. Health professionals involved in delivering maternity services were also invited to take part in Focus Groups.

The outcome of these consultations reflected the current consensus views of women and health professionals about what the philosophy of a modern maternity service should be. The consultation also put forward suggestions as to how the ultimate goal of a healthy mother, a healthy wanted baby, and a happy and confident start to family life could, and should, be achieved.

Although the women represented in the study reflected a wide range of backgrounds, experiences and needs, a clear and consistent picture of what women actually want from maternity services emerged from the data. These findings are in keeping with other consumer studies. The main findings were:

• women frequently described health contacts during pregnancy, childbirth and in the postnatal period as fragmented and impersonal;
• women were often seen by a range of different professionals, at different times, who had very different approaches, styles and ways of working. They worked in different and inconvenient locations, and often did not appear to be aware of what other professionals had said to women during their maternity care, or what care they had received;
• that when women had good experiences it was because they had good relationships with health professionals, everyone involved in their care was aware of what other professionals had said or done, and they listened to what the woman herself felt or wanted;
• integrated care and good quality relationships were achieved most effectively when there was continuity of care. Continuity of carer was particularly valued;
• but what seemed to matter most was that everyone involved in care-giving knew what other health professionals had done or said, had a shared approach to that woman's care, and knew about the woman and what she herself wanted;
• where this happened, care was felt to be individualised and personal, and as a result, women felt more involved in decisions affecting their care;
• integrated, individualised and involved care is most effectively achieved by making sure that continuity of care permeates the service and that:
• there is consistency of service provision across NHS Boards;
• different professional groups have shared protocols for service delivery;
• all professionals involved in service provision share information about each woman with each other and with the woman herself.

These themes have been integrated into this Framework. A detailed background to the consultation process is provided in Appendix 2.

Scotland's demography and geography must also be considered in providing maternity services.

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