Christine Duncan
Change Manager, Maternity Services
Child and Maternal Health Division
Christine.Duncan@scotland.gsi.gov.uk
0131 244 4634
What we want to do today?
• Outline the
rationale and aim
of the target
• Provide an
overview of the
evidence
• National Supportoverview and
discussion
A refreshed Framework for Maternity
Care in Scotland
Refreshed
not new….
http://www.scotland.gov.uk/Publications/2011/02/11122123/0
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
www.time.com/time/printout/0,8816,2020815,00.html
Unequal Pregnancy Outcomes
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
Health Inequalities- Social and lifestyle
factors
• 14741- 25% 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
http://www.cemach.org.uk/PublicationsPress-Releases/ReportPublications/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 includingsexual 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:
http://www.scotland.gov.uk/Publications/2011/01/130956
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
Prematurity (<37 wks gestation) rate per 1,000 total births by deprivation - 2008
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
1 - Most Deprived
2
3
4
5 - Least Deprived
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 circumstancesmaternal 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 11-14 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
Physical
Cognitive
Location
Timing
AwarenessCommunicationlanguage and literacy
Staff behaviour/attitudes
Transport
Fear
‘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, 2005.12).
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, 2005.35).
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, 2004.79).
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
• http://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
http://www.scotland.gov.uk/Topics/Health/NH
S-Scotland/Delivery-Improvement