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90The work streams of the National Framework for Service Change do not specifically cover
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
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.
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
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
206 Review of NHS Scotland
Recommendations For Action
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.
We recommend that:
•High quality maternity care should be based on the available evidence about clinically safe
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
• 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.
Maintaining Local Services
100Maternity services should continue to be delivered as locally as possible. It is important to
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
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.
We recommend that:
•Regional Maternity Planning Groups must be established and maintained.
• 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
• Local planning and commissioning of maternity services should take place within this
• 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
• New models of service delivery, manpower roles and responsibilities and technological
advances should be nationally evaluated and best practice disseminated through
• 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.
National Review of Services
102Local Maternity Services should be subject to on-going review and monitoring subject to the
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
We recommend that:
•The National Maternity Services Workforce Planning Group should ensure the on-going
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
208 Review of NHS Scotland
103Service Users, Voluntary Groups and Communities should all be encouraged to be involved in
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.
We recommend that:
•The Scottish Executive and NHS Boards should put in place systems to encourage and
support user involvements in service development.
• Maternity Service Liaison Committees should be developed and maintained within
• 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.
Maternity Services Support Group
104A formal, high profile and well established mechanism exists to promote and develop child
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.
We recommend that:
•A National Maternity Service Support Group should be established
• The remit of the Child Health Support Group should be extended to include maternity