General overview
Background
NHS Boards have embraced current maternity policy direction as outlined in the
Framework for Maternity Services in Scotland1 and Report of the Expert Group on Maternity Services (EGAMS).2 These reports endorse the promotion of
pregnancy and childbirth as normal life events, advocating woman centred care, with services and care tailored to need. They recommend community focussed, midwife led care for healthy women experiencing uncomplicated pregnancies, and multidisciplinary maternity team care for women with more complexity. It is well recognised that women should also have ongoing medical care provided by their general practitioner (GP), as required, throughout the pregnancy episode. While there has been significant progress made towards implementing this policy, specific key principles are still to be achieved in some Boards. Examples include, positioning the midwife as the lead professional for the majority of low risk women, or ensuring a normal birth pathway for healthy women regardless of birth setting.
Context
The Scottish Government Health Directorates (SGHD) established the multiprofessional Keeping Childbirth Natural and Dynamic programme (KCND), aiming to support implementation of the Framework and EGAMs reports at NHS Board level. KCND aims to promote mutliprofessional working and implementation of care pathways for women and babies based on need. The programme has the support of the Royal Colleges of Midwives; General Practitioners; Obstetricians and Gynaecologists; Paediatrics; and Anaesthetics. KCND has progressed in partnership with these Colleges and other stakeholders including: NHS Quality Improvement Scotland (NHSQIS), NHS Education Scotland (NES), Chief Scientist Office Nursing, Midwifery and Allied Health Professions Research Unit (NMAHPRU), Health Scotland, service user representatives and all NHS Boards.
NHS Scotland's Action Plan, Better Health, Better Care3 makes specific reference to KCND objectives, re-iterating the importance of effective maternity care delivered by appropriately skilled professionals. It highlights the potential for impacting on health inequality through early risk assessment, tailored antenatal care and maximising opportunities for building early relationships with families antenatally. Specific targets for NHS boards include creation of maternity leads for public health priorities, such as smoking cessation and alcohol management, with a HEAT target of 33% of children being exclusively breastfed by 2011. KCND offers a unique opportunity to ensure that nationally agreed multidisciplinary maternity care pathways incorporate such priorities.
KCND is in keeping with wider United Kingdom (UK) Department of Health Policy, as outlined in the publication Maternity Matters4 and shares a number of key principles and objectives. Similar to England and Wales, the demographics of women accessing maternity services in Scotland is shifting. All four UK countries are experiencing a rising birthrate trend, economic and social migration and increasing case complexity, due rising maternal age and improvements in the management of longterm medical conditions. While it is recognised that pregnancy and childbirth are normal life events for many healthy women, there is a need to ensure that specialist medical services are readily available for those who require them. These factors, coupled with introduction of European Working Time Directives and Modernising Medical Careers frameworks, require maternity and associated services to tailor resources to need. Subsequently, many NHS Boards are currently taking forward this challenge, focussing on providing the appropriately skilled professional for women in the appropriate place. Within NHS Scotland, KCND is a key lever supporting implementation of multiprofessional working and advocating that scarce resources are tailored to need.
KCND aims and objectives
KCND aims to maximise opportunities for women to have as natural a birth experience as possible, through: providing evidence based care; reducing unnecessary intervention; ensuring informed choice; and developing multiprofessional care pathways. Key objectives are to support the following at NHS Board level:
Implementation of national referral criteria and care pathways
Universal referral criteria have been produced by NHSQIS, to facilitate streaming women to the appropriate care package for their need during the antenatal, intrapartum and postnatal periods. Evidence based normal schedules of antenatal and postnatal care have been produced, alongside a normal birth pathway which includes guidance for the care of healthy women with uncomplicated pregnancies. These will be consulted on during summer 2008, with final drafts anticipated by December 2008. It is recognised that women with more complexity will require antenatal, intrapartum and postnatal care tailored to need and delivered by the wider maternity team. It is therefore not intended to produce pathways for this, as individual women will require different care packages. However, it would be assumed that the above schedules and pathways would form the basis for all antenatal, intrapartum and postnatal care.
NHSQIS will also produce evidence based guidance for the final postnatal examination, which is currently undertaken 6 weeks. It is recognised that GPs, obstetricians or other colleagues currently provide this service in some areas and guidance should encompass the skills and competencies required in relation to this.
Implementation of the midwife as the first point of professional contact in pregnancy
Once the woman has confirmed her pregnancy, it is expected that she will self refer or be directed to a midwife who, where possible, should be the first point of professional contact.1,2,4,5 The midwife should undertake an initial risk assessment, making reference to nationally referral criteria and stream the women to the appropriate care package for her individual need.1,2,4 This will facilitate early risk assessment and booking with maternity services prior to 12 weeks gestation.5 To ensure robust history taking, it will be important for the midwife to communicate with the GP in relation to relevant past medical history.
Implementation of the lead maternity professional based on risk
Normally the midwife would be lead professional, with caseload responsibility for healthy women experiencing uncomplicated pregnancies, throughout the antenatal, intrapartum and postnatal periods.1,2,4,5 Where the midwife is caseload holder, the midwife would be named as such on the Scottish Women Held Maternity Record (SWHMR) and would have professional accountability for the case, as outlined in the relevant Nursing and Midwifery Council regulations.6,7 This would be explicit in Board statistical returns to the Information Services Directorate of SGHD.
Women with more complex needs would have obstetric led care, delivered by the wider maternity team, including midwives, throughout this periods.1,2,4,5 Within this team, neonatologists would have initial responsibility for medical care of the ill baby. Where the obstetrician is caseload holder, the obstetrician would be named as such on SWHMR and would have professional accountability for the case. This would also be explicit in Board statistical returns.
It is expected that women will transfer between midwife led and obstetric led maternity team care as risk alters.1,2,4,5 However, it is anticipated that women may continue to have choice in relation to the caseload holder.
It is recognised that GPs have ongoing responsibility for the woman's medical care throughout pregnancy and post birth, including responsibility for the baby's ongoing medical care as required. Care of healthy mothers and babies normally transfers to the health visitor anytime from day 10 postnatal and they have responsibility for the ongoing care of healthy children until school age.
Implementation of normal birth pathways regardless of birth setting
It is anticipated that all women who meet the national criteria for the midwife led normal birth pathways would have the opportunity to join these pathways. This would be implemented in all maternity unit and labour suite settings across NHS Scotland. Within these pathways, it is expected that healthy women presenting in labour with uncomplicated pregnancies, would not routinely have an admission carditocograph (electronic monitoring of the fetal heart).
KCND Workstreams
NHS Boards
Through SGHD funding allocations, all mainland NHS Boards have or are in the process of appointing a Consultant Midwife, to work with the multidisciplinary team to implement KCND locally. To date 10 Boards have appointed and all Boards have nominated a programme lead. Quarterly progress reports are submitted from Boards to a national steering group chaired by the Chief Nurse.
NHSQIS
In 2007, SGHD held a stakeholder event for clinically based obstetricians and midwives to inform the format for the referral criteria and care pathways. The aim was to test suitability, usability and acceptance of different options at clinical practice level across the service. Following presentation of a variety of formats, the consensus was that a Traffic light/flow chart example was preferred and would be most easily used in practice. QIS have produced draft national referral criteria and care pathways following this type of format, which will be consulted on during the summer.
NES
NES are taking forward the leadership and change management support to underpin KCND. In 2007, the focus was on midwifery and a leadership programme for the newly appointed Consultant Midwives is nearing completion. Multidisciplinary work has commenced, through 2 events with key stakeholders to explore the cultural change required to support implementation of KCND objectives at local level.
Health Scotland
Health Scotland will be engaged to develop any national literature and publications to support implementation of KCND objectives.
NMAHPRU
In 2007, NMAHPRU completed a comprehensive literature review to underpin KCND. The review addressed four main subject areas: Midwifery Led Care, Antenatal Care, Intrapartum Care and Postnatal Care. Where nationally agreed guidelines were available, these were summarised and the review includes published literature from 1997 onwards. Subsequently, an evaluation advisory group has been established and NMAHPRU is working alongside partners to lead on a programme of evaluation.
References
1. Scottish Executive (2001) A framework for maternity services in Scotland. Edinburgh: The Scottish Office.
2. Scottish Executive (2003). Implementing a Framework for Maternity Services in Scotland. Overview Report of the Expert Group on Acute Maternity Services. Edinburgh: The Scottish Office.
3. Scottish Government (2007). Better Health, Better Care: Action Plan. Edinburgh: Scottish Government.
4. Department of Health (2007). Maternity Matters. Choice, access and continuity of care in a safe service. London: Department of Health.
5. CEMACH (2007). Saving Mother's Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. London: CEMACH.
6. NMC (2004). Midwives Rules and Standards. London: NMC.
7. NMC (2004). The NMC code of conduct: standards for conduct, performance and ethics. London: NMC.