The Following is an extract from  -
Building A Health Service Fit For the Future
Chair Prof David Kerr
Published 25 May 2005
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maternity services. The S.E. Framework for Maternity Services and reports of the Expert Group

on Acute Maternity Services already set a framework to plan and deliver such services across

Scotland. However we felt it important to report on progress on implementation and make

recommendations for further work.

91 For the purposes of planning and delivery the “maternity” service includes all the elements of

childbearing from pre-conception and antenatal care, preparation for parenthood, through to

childbirth, postnatal support, and all aspects of neonatal care. Support throughout these phases

is multi-faceted, multi-disciplinary and will be unique to each and every woman and her family.

To support the provision of such a service and set a vision and philosophy for these services the

Executive produced ‘A Framework for Maternity Services in Scotland’ in 2001 and the reports

of the Expert Group on Acute Maternity Services (EGAMS) in 2003.

A Framework for Maternity Services in Scotland

92 The Framework for Maternity Services stated that:

‘Maternity Services should provide a woman and family-centred, locally accessible, midwife

managed, comprehensive and effective model of care during pregnancy and child-birth, with

clear evidence of joint working between primary, secondary and tertiary services’.

The Framework also stresses the importance of evidenced based high quality care; the normality

of childbirth and maternity; maternal choice; holistic assessment of needs; person centred care;

one-to-one midwifery care in labour; clear pathways of referral within the incremental care

pathways of tiered care; support for breastfeeding; clear protocols for comprehensive risk

management and assessment; clear communication between clinicians and families and

transport issues.

The Expert Group on Acute Maternity Services

93 Following the Framework, the short-life Expert Group on Acute Maternity Services examined

the principles of the Framework and how they should be applied to care during childbirth

(intrapartum care). The group reviewed the available evidence and agreed that the majority of

care should be provided as locally as possible and, that where possible, midwives should be the

lead professional for low risk women, but within the appropriate referral pathway and risk

management strategy. It suggested core competencies and skills for all maternity professionals

at each level of care, and highlighted the importance of a multi-professional, multi-disciplinary,

integrated approach to education. Further it highlighted the importance of regional planning in

the context of local and national planning, multi-professional working, good communication

and IT systems, consumer involvement and transport systems.

205 A health service fit for children

94 The principle conclusion of the Group was, that the current configuration of acute maternity

services was no longer sustainable and that change was needed. Maternity Services are subject

to the same pressures as many other health services that have been brought about by training

reconfiguration, recruitment and retention difficulties, changes to contracts and other workforce

issues. However, there are a variety of reasons why the current configuration of maternity

services is no longer sustainable including significant demographic changes: a decline in birth

and fertility rates, reduced family sizes, commencing families at an older age; and changing

expectations of all stakeholders, technological advances in care, and parental choice.

Regional Planning

95 Following the publication of EGAMS the Scottish Executive issued funding to each Regional

Planning Group to enable them to facilitate real regional planning for maternity services. Given

the differing priorities and stages of progress this work has taken a different shape in each of

the 3 regions. All 3 regions now have a sub-group for maternity services and are taking forward

the implementation of EGAMS through this mechanism. They have been encouraged to work

together and across regional boundaries.

National Maternity Services Workforce Planning Group

96 This group was established in 2003 under the chairmanship of Professor Andrew Calder with a

multi-professional membership, including regional representatives, national bodies and Royal

Colleges. The role of the group is to review the current workforce and service profile, identify

gaps, recommend solutions and from this advise and support NHS Boards, Regional Groups and

other relevant bodies.

97 The interim report of the National Group will be published in Spring 2005 and this will set out

the current profile of the maternity workforce, including neonatology and anaesthesia, and set

out further action taking into account the various drivers for change and emerging models of

service delivery.

Scottish Multi-professional Maternity Development Programme

98 EGAMS identified core skills and competencies necessary for all healthcare maternity staff

providing intrapartum care in each level of maternity care within the tiered approach, including

antenatal, intrapartum, postnatal and neonatal care. In order to achieve these competencies a

Maternity Development Programme was established to develop and deliver national evidencebased

and clinically focussed multi-professional courses. The Programme is managed by the

Scottish Multi-professional Maternity Development Group and each course within the Maternity

Development Programme is validated by NHS Education for Scotland and accessed via

www.scottishmaternity.org .

206 Review of NHS Scotland

Promoting Normality

99 Midwives see all women and their families antenatally, during labour and postnatally and have

a strong role in ensuring that care throughout pregnancy and beyond is appropriate for each

individual case and that choices about birth are properly informed. In order to increase the

profile of midwives as lead practitioners for low risk women, midwives should be the first point

of contact once a woman thinks or establishes that she is pregnant. In doing this the midwife

will take an appropriate history, develop a care plan which focuses on the woman and

maximising the opportunities for a normal birth, but in a risk management context and refer to

the Obstetrician and Neonatologist as appropriate. Skilled one to one midwifery care in labour

increases the opportunities for a woman to have a normal birth and a healthy postnatal period

and reduces the need for unnecessary medical intervention.

and effective practice, and must be woman and baby centred.

• A strong multiprofessional team approach is integral for the delivery of an appropriate

seamless maternity services.

• The principles in “A Framework for Maternity Services in Scotland”, especially the tiered and

incremental framework for antenatal, intrapartum, postnatal and neonatal care, should be

fully implemented.

• The concept of risk assessment and management should be developed at all levels of

maternity service provision.

• The role of the midwife as the lead professional in low risk pregnancy, childbirth and

peurpeum should be promoted and supported.

• One to one maternity care should be the norm in childbirth.

• Community Maternity Units, where deliveries are midwife-led, should be developed, either

standalone or co-terminous with a Consultant-led Unit.

• All healthcare maternity professionals should have the appropriate skills and competencies to

deliver the appropriate service at each level of care, supported by appropriate communication

and explicit referral networks for required incremental care.

• The rates of caesarean section and instrumental vaginal delivery should be regularly audited

and reviewed locally and nationally.

note that the majority of antenatal and postnatal care, and intra-partum care for low risk

women is available in the local community but sustainable and more specialist services for

childbirth may not be as easy to maintain. There is no such entity as “zero risk” for women

who are pregnant and giving birth – an element of risk applies to all pregnancies and all

childbirths.

101 The majority of medical needs of most critically ill newborn babies can be met by the neonatal

intensive or high dependency care within most consultant led maternity units. Neonatal surgery

and the associated intensive care needs, especially for those babies with complex congenital

abnormalities, require specialist surgical and other complex interventions provided by specialist

207 A health service fit for children

multi-disciplinary teams, which can only be provided in a smaller number of specialist centres.

• Maternity services should be planned regionally with the involvement of all relevant clinical

disciplines, the Scottish Ambulance Service and consumers. Some specialist services should be

considered nationally.

• Local planning and commissioning of maternity services should take place within this

regional context.

• Local and regional referral pathways for increasing levels of all specialist maternity care

should be developed.

• Protocols and guidelines for women in labour and specialist neonatal care should be

developed.

• New models of service delivery, manpower roles and responsibilities and technological

advances should be nationally evaluated and best practice disseminated through

communication networks.

• Formal communication and information networks should be developed between all maternity

clinicians, both regionally and nationally.

• The configuration of maternity units providing the various levels of intra-partum care should

be agreed and developed regionally.

• The configuration of maternity units providing the different levels of neonatal care should be

agreed and developed regionally.

• The three Regional Neonatal Transport Services should be developed and maintained to ensure

a quick, effective and safe retrieval and transport of neonates to specialist care, when

appropriate and required.

• Neonatal surgery and the associated neonatal intensive care requires to be planned and

delivered in conjunction with fetal medicine as an integral part of maternity services, taking

the configuration of specialist paediatric services into account.

most up to date evidence and best practice. Where necessary national policies should be

reviewed and changed in consultation with NHS Boards, Regional Planning Groups and

consumers.

monitoring of the service and workforce profile and assist Regional Groups to map current

and future services.

• The Scottish Executive should continue to review national policy documents, in conjunction

with NHS Boards and consumers and identify areas for action.

• Quarterly meetings between the Scottish Executive, NHS Health Scotland, NHS Education for

Scotland, NHS Quality Improvement Scotland, National Services ISD and the Scottish

Ambulance Service should be arranged to map and monitor national work to support

maternity services.

208 Review of NHS Scotland

developing and monitoring maternity services. Locally this is vital as maternity services do not

only impact upon the patient (ie mother / child) but the wider family.

support user involvements in service development.

• Maternity Service Liaison Committees should be developed and maintained within

NHS Boards.

• Women must be informed about risk with unbiased evidence based information to help

them decide where to receive care and give birth. Professionals should balance maternal

choice, demand and need against assessment of risk and the availability of services.

health and child health services in the form of the Child Health Support Group. This group does

not take into account maternity services, although there is a significant overlap with regard to

neonatal services, which are an integral part of maternity services.

Or

• The remit of the Child Health Support Group should be extended to include maternity