1. Dr Corinne Love Senior Medical Officer Maternity and Womens’ Health
The Best Start The Future of Maternity and Neonatal Services in Scotland
Dr Corinne Love
Senior Medical Officer
Maternity and Womens’ Health

3. Current Landscape NHS Scotland 5 million+ people 60,000 births
14 health boards
8 support boards
NHS Education for Scotland
Healthcare Improvement Scotland
35 maternity units
(17 consultant led)
Policy and Professional Landscape
England - 53,012,456
Northern Ireland - 1,810,863
Scotland - 5,295,000
Wales - 3,063,456 (2011 Census Scot) 3

4. A Refreshed Framework for Maternity Care in Scotland
The Maternity Services
Action Group
The Scottish Government, Edinburgh 2011
Policy Landscape
There are several pertinent and relevant policy documents in Scotland which I am going to refer to
findings both align and challenge the direction of travel for Scottish maternity and neonatal services.

5. Am sure you will all be aware of Scotland’s CMO’s first report ‘Realistic Medicine’ which focussed on these 6 areas and the follow up report in 2017 ‘Realising Realistic Medicine’
These National reports provide the framework for professional change generally across Scotland, not just within maternity settings.
One of the areas to focus on is around reducing unnecessary variation, which fits well with the NMPA aims and findings.
One of the ways Scotland is enabling and assisting professional change is through the work of the SPSP

8. THE BEST START A Five-Year Forward Plan for Maternity and Neonatal Services

9. Maternal Mortality in the UK
Professional Landscape
Reporting on UK deaths for over 60 years
Represents a gold standard internationally

10. Maternal Mortality

11. 2016 MBRRACE Report
241 women died in during pregnancy or up to 6 weeks after
Death rate of 8.54 per 1oo,ooo maternities (lowest ever)
81 direct deaths
119 indirect deaths (psychiatric causes)
41 coincidental
323 late deaths (after 6 weeks. Includes direct and indirect)
Total 564
Maternal suicides reclassified by WHO as a direct cause of maternal death. Rate unchanged since 2003
Maternal suicides are now the leading cause of direct maternal deaths occurring within a year after the end of pregnancy

12. Indirect Maternal Deaths 2011-13

14. Key Messages
There continues to be a significant decrease in the maternal death rate in the UK
No significant change in the rate of indirect death over the last 10 years
Majority of women who died had pre existing medical or mental health problems or both
Specialist perinatal mental health care matters
Communication and Multidisciplinary working
Continuity of care
Perinatal mental health clinical networks should be established
Red flags
Support and education for families
Greater awareness of this report amongst mental health staff

15. Death is the Tip of the Iceberg
Morbidity
10-15% suffer anxiety or depression during pregnancy and first year after giving birth
women* per year
in Scotland

16. THE BEST START A Five-Year Forward Plan for Maternity and Neonatal Services

17. Aim of the Review
To examine choice, quality and safety of maternity and neonatal services in light of current evidence and best practice
To consult widely with the workforce, NHS Boards and service users
To make recommendations for a Scottish model of care that:-
contributes to the Government’s aims of person-centred care,
provides the right care for every women and baby every time
gives all children the best start in life
Remit
To examine choice, quality and safety in light of current evidence and best practice;
Choice
Look at informed choice and consent,
What is realistic and practical in offering women choice in maternity services?
And for families in neonatal services?
Can we provide choice in all care settings?
Safety
How safe are our services?
Do we have the right risk assessment protocols, do we have consistency of safe service provision, at all times and in all places?
Do we have a consistent approach to review and learn lessons from incidents, and share this learning?
Are our culture and behaviours compromising safety?
Quality
Are our risk assessment protocols, referral pathways and models of maternity and neonatal care as good as they can be?
Have we got the right local, regional and national layers of care?
Does data collection work to drive service improvement?
Have we got the right balance of skills in the right places, are we using them effectively and is the model sustainable?

18. Vision
All mothers and babies are offered a truly family-centred, compassionate approach to their care, recognising their own unique circumstances and preferences
Fathers, partners and other family members encouraged to be part of maternal and newborn care
Women experience real continuity of carer, across the whole maternity journey, with additional tailored support for vulnerable families
Services are redesigned using the best available evidence, to ensure sustainability and maximise the opportunity to support normal birth processes
Multi-professional team working is the norm within an open and honest team culture, with everyone’s contribution being equally valued
Remit
To examine choice, quality and safety in light of current evidence and best practice;
Choice
Look at informed choice and consent,
What is realistic and practical in offering women choice in maternity services?
And for families in neonatal services?
Can we provide choice in all care settings?
Safety
How safe are our services?
Do we have the right risk assessment protocols, do we have consistency of safe service provision, at all times and in all places?
Do we have a consistent approach to review and learn lessons from incidents, and share this learning?
Are our culture and behaviours compromising safety?
Quality
Are our risk assessment protocols, referral pathways and models of maternity and neonatal care as good as they can be?
Have we got the right local, regional and national layers of care?
Does data collection work to drive service improvement?
Have we got the right balance of skills in the right places, are we using them effectively and is the model sustainable?

19. Shaping the Recommendations
Evidence and Data
REVIEW RECOMMENDATIONS
Sub Group Reports
Feedback from Engagement

20. Perinatal mental health (4) Remote and rural challenges
Chair: Jane Grant
CE, NHS Forth Valley
Launched 20th Jan 2017
Perinatal mental health highlighted as a key priority for maternal and infant health and wellbeing
Recognised the opportunity and correlation between improved maternal health and lifelong health, wellbeing and attainment in children
76 Recommendations
Vulnerable women (3)
Perinatal mental health (4)
Remote and rural challenges
Health and social care integration – mental health is an ideal example of where this could and should work well.
Principle of the report – aligned with Scottish Government priorities around health and social care integration.
Recommendations around vulnerable women recognised the wide range of medical, social and psychological reasons which can lead to vulnerability.
Perinatal mental health: was a consistent theme raised by staff, third sector organisations and users around Scotland when all Boards were visited. Particular areas highlighted were: Access to and range of services, need to improve the skills of staff in this area and need to increase awareness of the issue.

21. Person-centred maternity and neonatal care
Key Recommendations:
Continuity of carer
from primary midwife and obstetrician
care co-located for the provision of community and hospital-based services.
Person-centred maternity and neonatal care
Relationship-based, personalised care
Aiming to keeping mums, babies & families together
Safe & family centred neonatal care
Multidisciplinary team care
Women receive the level of care they need
clear referral pathways

22. Safe, high quality and accessible care
Development of community hubs
Postnatal neonatal care
Specialist maternity and neonatal care co-located
Support for vulnerable women and improved perinatal mental health services
Neonatal care
Three to five neonatal intensive care units should be the immediate model for Scotland, moving to 3 within 5 years.
Development of a national model for 7-day neonatal community services.

23. Perinatal Mental Health Recommendations
Early and equitable access
Clear referral pathways
Adequate provision of staff training
The Best Start aligns with the Mental Health Strategy
Psychological support for parents of babies in the NNU
Awareness and use of third sector support agencies

24. Implementation
National Implementation Programme Board established – reps from across the service, professional bodies and service users
Chaired by Jane Grant, Chief Executive of NHS Greater Glasgow and Clyde

25. National Implementation Structure

26. Sub Groups - Continuity of carer and local delivery of care
Continuity of Carer model of care
Operations of FMUs
Community Hubs
Support workers in the community
Postnatal Neonatal Care
Alignment with Obstetricians
Caseload and core hospital based midwives

27. Sub Groups - Perinatal Services
Neonatal Intensive Care Unit locations
Risk Assessment Tool
Pathways
Cot locator system
Cot availability protocol
Neonatal transfer staffing model
Medical care outwith maternity setting

28. Sub Groups - Workforce and Education
Workforce Planning
National education resources
Protected training time
Maintaining skills
Examination of the newborn
Remote and rural skills
Non registered staff roles

29. Locally led recommendations
NHS Boards will be empowered to drive forward many of the recommendations at local or regional level where possible and practical to do so
23 out of 76 recommendations suitable for delivery at a local level
Local area implementation leads have been identified in all geographic NHS Boards

30. National linked projects
Neonatal expenses
Maternity network
Perinatal mental health
Refreshed information for parents
Single MCN
Electronic records
Caesarean section study
Adverse events

31. Early Adopter Boards NHS Forth Valley NHS Highland NHS Lanarkshire
NHS Lothian
NHS Greater Glasgow & Clyde (Clyde only)
Announced Sept 2017

32. Organisational Changes
Continuity of care and carer
Increasing choice for place of birth
Re – designing neonatal care
Postnatal care
Transitional care
Community care
Community hubs
There are several significant organisational changes underway as part of the recommendations and improvement work planned.
Continuity of care and carer I have already mentioned. However maternity and neonatal care are inextricably linked here and it will be impossible to move forwrad with one and not the other.
Scotland had already recognised some of the limitations women have for choice of place of birth and this is another important area being addressed moving forward.
Neonatal care redesign aims to keep mum and baby together by providing as much of that care as possible outwith neonatal units, whether that be in the post natal wards with a new model of transitional care or in the community with enhanced community neonatal care
And of course having the smallest sickest babies cared for in fewer centres.
The recommendation for the setting up of community hubs is aimed at both maternity and neonatal care
So many of the organisational changes see us moving forward together and its impossible to do one without the other.

33. Professional Changes
Revision of ‘risk’ pathways to much more individualised approach
Criteria for Midwifery and Obstetric units – high risk fetal and maternal conditions
Developing and supporting high performing multidisciplinary teams – work and train together
There are also recommendations requiring professional changes but which would also benefit from maternity and neonates working closely together to achieve the best outcomes.
Antenatal risk assessment was highlighted by women and staff as being too restrictive currently. There is a national risk assessment tool which is used but once assigned to a risk category is seems difficult to alter that during pregnancy as circumstances and situations change, so there is work currently underway to revise and individualise antenatal assessment better with an aim for labour and delivery outcomes to be the best possible.
One of the other ways being looked at to achieve this is to review and provide national guidance on women who should be delivered in an obstetric unit, with a view to increasing the proportion and reducing the variation in women for whom delivery in a midwife led setting would be better.
This is also aimed at ensuring the high risk fetal and maternal conditions are cared for in the correct place.
Another of the professional recommendations is around multiprofessional team training. Obstericians, MW and anaesthetists do this already together, but is this an area where we could consider moving forward together with neonatology too.
Routine examination of the newborn – the recommendation is for this to be performed by midwives, which is clearly going to require collaborative working to take this forward.
And both maternity and neonatal transport considerations are going to require us all to work closely together to take this forward.
Greater shared decision making for women and families
Emphasis on care close to home

34. Supporting the Changes
National maternity and neonatal dashboards
Protected staff training time
Single maternity care electronic system
Scottish electronic women’s maternity record
Single Maternity and Neonatal Clinical Network

36. Communication Twitter - @SGChildMaternal
Blog -
Website -
Newsletter – Issued 10 May – give us your address! –
Local lead in each Board