Christine Duncan Change Manager, Maternity Services Child and Maternal Health Division

What we want to do today? Outline the rationale and aim of the target Provide an overview of the evidence National Support- overview and discussion

A refreshed Framework for Maternity Care in Scotland Refreshed not new….

Why did we refresh the framework? Strengthen the contribution NHS maternity care makes to: 1.Improved maternal and infant health And 2.Reduced health inequalities between and across groups of women and infants

Biological ‘postcards’ low birth weight, heart disease and diabetes Maternal stress and child behavioural/ psychological problems

Perinatal mortality rate - most deprived was 8.8/1000 births 6.5/1000 births in the least deprived A similar gradient was recorded for prematurity, low birth weight and small for gestational age babies ISD 2009 Unequal Pregnancy Outcomes

Health Inequalities- Social and lifestyle factors % babies born into areas of highest deprivation in Scotland (ISD) 30% of pregnant women in the most deprived areas self-reported as current smokers compared to 7% in more affluent areas (ISD) 11% of women who die during pregnancy are substance misusers ( CMACE) (strong relationship between inequality substance misuse)

ACCESS MATTERS 20% of women who died either first booked for antenatal care after 20 weeks gestation, missed over four routine antenatal appointments, or did not seek care at all 81% of women who died of direct or indirect causes and who were in abusive relationships found it difficult to access or maintain contact with maternity services Press-Releases/Report- Publications/Maternal-Mortality.aspxhttp:// Press-Releases/Report- Publications/Maternal-Mortality.aspx

Principle 4 of the refreshed framework for maternity care All women have access to and uptake of safe and effective maternity care Systems are in place to ensure that all women are offered the option of attending a midwife as the first professional contact, ensuring women are also aware that the choice of seeing their GP at any point in their pregnancy is available Antenatal care services are tailored and proportionate to local population need. Inequalities in access to maternity services are identified and effectively addressed. Antenatal care services are promoted through all appropriate NHS and local authority services including- sexual and reproductive health services, mental health services, community addiction services, specialist mental health

Service Improvement Measures tailoring reach to women and babies known to be at risk of poorer outcomes auditing uptake of antenatal services prioritising measurable improvements in uptake by women at risk of poorer outcomes. working with Community Planning Partners, including the Third sector to improve access to maternity services prioritising early access and sustained engagement with maternity services amongst those women and their babies at risk of poorer maternal and infant health outcomes. effective communication and collaboration between maternity services and primary care services, with specific processes where these services are not co-located. effective liaison, communication and pathways between maternity services, primary care, public health nursing and other NHS services working with women at risk of poorer outcomes.

development via evidence and engagement Development of the antenatal inequalities guidance: 21/0 21/0 Focus groups with key stakeholders Implementation support group-NHS corporate and professional groups

Maternity care matters Strong feeling from maternity services that the profile maternity care has at Board level does not match the level of importance ascribed to it in policy rhetoric…….

The Target At least 80% of pregnant women in each SIMD quintile will have booked for antenatal care by the 12th week of gestation by March 2015 so as to ensure improvements in breast feeding rates and other important health behaviours.

Refreshed National Performance Framework Level 1-Quality Outcome Indicator Appropriate for gestational age birth weight-healthy birth weight Level 2- HEAT Target Improving early access to antenatal care Level 3 -Quality measures Draft quality measures (national and local measures)

Improving access for all women- the social gradient 77% of people in poverty live outside the 15% 'most deprived' data zones

Rationale The first two trimesters following conception are vitally important. They are periods of significant fetal development, and are when fetal development is most vulnerable to the impact of adverse maternal biopychosocial circumstances- maternal stress, use of tobacco, drugs and alcohol and poor nutrition

Rationale….. Pregnant women are highly motivated to do all they can to ensure the best outcomes for their babies and are therefore more likely to engage with and respond to behavioural change or modification support and information, including intentions in relation to breast feeding.

access to screening Ideally by 10 weeks- haemoglobanopathy screens Ideally 8-12 weeks for Haemoglobin,blood group, Rhesus antibodies, Screening for infectious diseases: blood test for syphillis, hepatitis B,HIV and rubella susceptibility Ideally between weeks for early blood test for Down’s syndrome NSD pregnancy and newborn screening programmes

What we mean by ‘booking’ a comprehensive assessment of a pregnant woman’s health needs- including an assessment of social and life style behavioural risks. assessment carried out by a registered, practising midwife the start of a therapeutic relationship which will carry on throughout the pregnancy. (hence continuity of carer as a quality measure)

POLICY AIM Improve early access to antenatal services to support mothers-to-be to breastfeed, improving maternal and infant nutrition, reduce harm from smoking, alcohol and drugs, and improve healthy birth weight. These health behaviours will be monitored through the Maternity care quality indicators. (LDP Guidance 2012/13)

Improving outcomes- an example Improved smoking cessation rates during pregnancy and after delivery will Reduce the number of low birth weight babies Reduce the number of admissions to neonatal units (evidence proven vi a number of economic modelling studies) Reduce the incidence of cot death Reduce asthma and diabetes in childhood

….mind the gaps! …measure specific improvements in access for: Women with disabilities Women and babies in BME communities Women from specific groups- substance misuse for example Equality groups- public sector duty to address this…..

Access- barriers and enablers PhysicalCognitive LocationAwareness- Communication- language and literacy TimingStaff behaviour/attitudes TransportFear ‘accessible’ sensory, physical disability Experience

Information and access “Targeted information materials should be used to raise understanding of maternity services and encourage women from ‘hard to reach’ groups to access them. This should refer women to information written for the general public, that has been made more accessible by using a range of formats, structuring the information carefully, using more visual prompts and making resources available in community languages. Inclusive information will reassure women from these groups that maternity services can cater effectively for their needs” (DH, ).

Promoting Access- Public Awareness “raise awareness of the existence of maternity services by developing accessible information materials that cater for different languages and literacy skills” (DH, ).

Working with partners “Voluntary sector and community organisations are often much better than the statutory sector at engaging with groups of people who face most difficulties or who do not access traditional sources of advice on health” (DH, ).

National Implementation support Group- 3 thematic support areas THEME 1. NHS Education Scotland developing a learning and development framework Key areas Knowledge and understanding of the impact of social inequalities Sensitive enquiry Effective response Communication Motivational approaches

National Support THEME 2. ISD leading -Information and data improvements/ development of quality measures set THEME 3. HIS leading scoping work regarding improved pathways- primary care, maternity services, public health nursing Resource allocation to National groups and local NHS boards Other support needed?- public awareness, information materials etc

KEY MESSAGES If the target is to improve outcomes: There needs to be concurrent improvements in quality Cognitive as well as physical access Part of a bigger improvement programme

Planning and improvement Support

Planning and improvement support Check list…..we can develop together? Evidence briefing paper- links ++++ Recommend…. NICE socially complex pregnancies Implementation tools eAssessment/xls/Englishhttp://guidance.nice.org.uk/CG110/Baselin eAssessment/xls/English

Planning and improvement support NHS Health Scotland Logic modelling- see paper for example Scottish Government Improvement Support Team HS-Scotland/Delivery-Improvement