The best start: five-year plan for maternity and neonatal care

A five-year forward plan for the improvement of maternity and neonatal services in Scotland.

Appendix H: Efficient Evidence Reviews: Conclusions

Definitions of Models of Care

No uniform definition of either maternity models of care or neonatal models of care was identified by this efficient evidence review. Crucially, in maternity models of care the primary focus is on who is delivering the care and making decisions (i.e. midwife, obstetrician) and/or the location of the care.

Whereas, in neonatal models of care, the focus is on whether or not the family were involved in the care and/or decision-making, and standards of how to involve parents in this process have detailed by both BFI UK ( UNICEF, 2012) and Staniszewska et al. (2012). However, as the maternity models of care focus more on service configuration and do not meet the definition of a model of care (as defined by Davidson et al., 2006), further consideration of how to operationalise a maternity model of care is necessary.

In the introduction to this report, a way forward was suggested to enable analysis of our rapid reviews, and the transparent presentation of material to the Sub-Groups.

Improving care, services and outcomes for women and babies from Vulnerable Population Groups

The lack of good quality evidence on interventions/actions for vulnerable groups in general was a consistent theme across the systematic reviews and was also identified by the NICE guideline on complex social factors and pregnancy (National Collaborating Centre for Women's and Children's Health, 2010) and is highlighted in the evidence summary by Woodman and Scott (2012).

However, key themes did emerge across the included reviews and primary studies for women in different vulnerable groups and should be considered in the model of care. Specifically, the importance of continuity of care in enabling women to develop trusting relationships. This can be facilitated through having a universal model of care, in which all women receive usual midwifery care and vulnerable women with additional needs receive additional care tailored to their individual needs, however, their care will still be co-ordinated by one primary midwife.

Such an approach is akin to the proportionate universalism approach proposed by Marmot (2010). Marmot argues that focusing solely on the most disadvantaged members of society will not tackle health inequalities. Instead, a universal model is needed, however, the scale and intensity of services delivered is proportionate with the level of disadvantage. Delivery of such a service, would require effective multi-agency working as outlined in GIRFEC (Steading, 2009).

Building a successful relationship was also consistently found to be dependent upon having non-judgemental staff who were empathetic and knowledgeable of the women's individual needs. Positive staff attitudes and knowledge could be improved by culturally sensitive training and education.

The ten Health Scotland's Principles (identified in the rapid review by Scott and Woodman [2010]) also provide guidance as to how all staff should treat women from vulnerable groups. Specifically: do good; do not harm; fairness; sustainability; respect; empowerment; social responsibility; participation; openness; and accountability

Another aspect that was found to be key was the need for effective communication, this refers not only to good interpersonal skills but also providing assistance for women with low literacy or for whom English is not a first language. There was some emerging evidence to support the use of culturally relevant lay workers, both for women with language difficulties and also to provide support more generally for women from other vulnerable groups. However, such an approach would require careful development and evaluation in different contexts before conclusions can be drawn regarding its ability to improve outcomes.

To conclude, there is clearly, therefore, no panacea for improving outcomes and experiences of care for vulnerable women and their babies. However, as the barriers to care were generally consistent across different vulnerable groups and indeed many of the vulnerable groups overlap, there is a need for highly accessible (i.e. multiple barriers addressed), respectful and technically high quality services for all women, with the ability to layer on/integrate additional care for specific conditions.

Models of Maternity Care for Critically Unwell Women

This efficient evidence review identified a paucity of evidence in maternal critical care configuration and provision, with only eight guidelines (the specifics of care provision not being underpinned by a strong evidence), one meta-ethnography and one qualitative primary study, four case studies and the two MBRRACE- UK reports as having any information pertinent to maternal critical care provision.

Nevertheless, from the available information we can still go some way to addressing the aims of this review. Specifically, in terms of determining the optimal model of care for maternal critical care provision which is acceptable for women, both critical care and maternity/obstetric needs must be considered, and normal midwifery care should be continued. This could in part be facilitated by training midwives in critical care skills and training critical care nurses in midwifery skills. In addition, women and babies should be kept together whenever possible to enable the establishment of attachment process and breastfeeding.

Due to the diverse nature of Scotland's geography and uneven distribution of population, different models could be used for different locations. For instance model one (a dedicated level 2 unit staffed by appropriately trained midwives with input from anaesthetists and obstetricians) may be suitable for an area with a high volume of women requiring such services, whereas the other approaches may be more appropriate in areas with a smaller amount of women requiring such services. The case studies do provide some illustration as to how model one could be delivered, however, it must be stressed that there is no well-conducted evidence to support this yet.

Organisation of Services for Childbearing Women and Babies across the Continuum

Highly processed evidence was identified in the form of Cochrane systematic reviews (n=12), the reviews and syntheses conducted as part of the development of the Lancet Series on Midwifery framework for quality maternal and newborn care (n=3), the reviews conducted as part of the English maternity services review (n=3) and NICE guidelines (n=3), as well as an additional three systematic reviews and evidence from highly relevant primary studies (n=7).

The highly processed reviews themselves were of a high quality, however, the included studies were of variable quality.

The evidence could be broadly sorted into the following categories: models of antenatal care; models of assessment during labour; models of intrapartum care (including transfers); models of postnatal care (including in-hospital and community care); models of breastfeeding care; and communication and relationships between women and maternity health care providers.

The reviews conducted for the development of the framework for quality maternal and newborn care identified some overarching principles that should be considered before the conclusions of each category are considered.

First, there is an important inter-relationship between effective practices and how care is delivered. More specifically, quality care should not dichotomise safety and choice. Instead, the service should ensure safety by implementing effective practices, tailoring care to their needs, and treating all women and babies with respect and enabling them to make informed decisions.

Secondly, there should be a universal model of care that runs across the whole continuum, whereby all women and babies receive normal midwifery care and those with additional needs receive the specific additional necessary care in conjunction with midwifery care.

Thirdly, the care provided should aim to optimise normal processes and avoid unnecessary intervention. Finally, care should be provided by an interdisciplinary team with the appropriate skill mix to care for a woman's individual needs, integrated across all settings.

Models of Care for Infants requiring Neonatal Services and their Parents

The review identified 30 systematic reviews, which were broadly divided into the following categories: parents' views and experiences of neonatal care units (n=11); methods for improving family-centred care (n=10); service configuration (n=5), transitional/discharge care (n=3) and workforce configuration (n=1). In addition, thirteen primary studies not included in the systematic reviews and which examined service (n=9) and workforce configuration (n=4), were also identified and included in the review. Guidelines from British Association of Perinatal Medicine ( BAPM) and the Department of Health, and a NICE quality framework were also identified as part of the review.

Some key themes did recur across the reviews of parents' views and experiences. Specifically, we can stipulate that families need to have the opportunity to have as much contact with their baby as possible and as far as possible be involved in providing care including breastfeeding and kangaroo care and also decision-making processes.

A family-centred model of care such as this one, enables parents to take on a parental identify and provide a sense of normality, at a very stressful time.

Models of Care for Infants requiring Neonatal Services and their Parents - continued

In terms of interventions/actions for improving family-centred care, a range of reviews of diverse interventions were identified. Two of these were high quality Cochrane reviews on the use of kangaroo care in stable infants which reported a wide range of benefits in terms of infant and mother outcomes. A well-conducted HTA review found strong evidence that short periods of kangaroo care (up to 1hr) increased the duration of breastfeeding up to one month post discharge.

BFI accreditation of the maternity unit was also associated with an increase in number of infants receiving any breastmilk - new guidelines for BFI accreditation for neonatal units are now available and may be beneficial - evaluation is needed.

Five systematic reviews examined configuration of services, specifically, regionalisation of care and neonatal transport. These reviews had a significant number of limitations in terms of included studies (e.g. date of publication, poor quality, lack of studies) so pertinent primary literature was sought instead. Together, these studies suggest that regionalization of neonatal services can increase the number of very preterm infants and VLBW infants being delivered in high activity neonatal intensive care units, and this may result in a decreased mortality rate for the most vulnerable infants. However, whilst centralisation of intensive care services may provide the optimal outcomes for very preterm, VLBW and very sick infants a different model of service provision would potentially be more appropriate for preterm infants who are more mature (>32 weeks) or higher birth weight (>1500g) and otherwise stable. Any service configuration that requires babies to move a distance from their home should pro-actively consider how to support parents to remain in close contact with their infants and also facilitate a return to more localised care as soon as possible to ensure parental involvement can be optimised.

Only one review examining workforce configuration was identified and this reported that low nurse-patient ratio was associated with higher mortality. Due to the lack of systematic review level evidence, primary literature was sought instead and four studies were identified. Again these studies have limitations, particularly as they are observational. However, they do suggest that under-staffing and over-crowding are associated with poorer outcomes for infants requiring care.

Finally only one systematic review, which included one study on early supported discharge was identified. Whilst this showed positive results, it highlights a dearth of evidence in this area and a need for further research to examine the safety, efficacy, acceptability, and resource implications of early supported discharge.

Improving Interprofessional Working

This review first sought to identify key issues in inter-professional working through examination of the Morecombe Bay Investigation (Kirkup, 2015) and the MBRRACE- UK reports (Draper et al., 2015, Knight et al., 2014, Knight et al., 2015), as well as examining the views of women and their families through the NHSScotland Maternity Survey (Cheyne et al., 2015) and the POPPY study ( POPPY Steering Group, 2009).

The Morecombe Bay Investigation, identified poor inter-professional working relationships between different groups of staff as being a major contributing factor. The MBRRACE- UK reports identified issues in lack of leadership for women with multiple care needs, poor information sharing (i.e. through medical records) leading to women receiving inconsistent information and staff being unaware of who is, and should be, involved in care. In addition, communication difficulties at the interface of different services (between primary and secondary care and also between different secondary care services) were also noted. This is particularly important in the context of risk escalation and de-escalation, whereby staff should feel supported in receiving advice from a senior colleague or a colleague in another discipline, about whether additional care for the woman is required.

Both the review of NHSScotland Maternity Services (Cheyne et al., 2015) and the POPPY Study identified that women were given inconsistent information from different staff, highlighting the need for consistent record keeping.

Secondly, this rapid review aimed to identify evidence (in the form of systematic reviews or primary studies) on interventions/ actions/ strategies to improve inter-professional working and also barriers and facilitators to inter-professional working. One of the first conclusions of this review is lack of evidence in inter-professional working in maternity care services, in particular, working with other NHS services (e.g. social work, criminal justice system). Nevertheless, five non-systematic reviews, one systematic review and 25 primary studies were identified and can be used to help distil core principles.

Three systematic reviews and ten primary studies examined the interventions/actions/strategies for improving inter-professional working. Inter-professional Education ( IPE) was the most commonly utilised strategy by six separate studies and detailed in one systematic review. IPE either took the form of pre- or post-qualifying education sessions or multidisciplinary emergency skills training.

The evidence around multidisciplinary skills training showed some promise, however as there is no measurement of how this translates into actual outcomes for women and babies, further evaluation on this level is therefore necessary. The evidence around IPE pre- and post-qualifying is very limited in terms of the quality of the studies, however, generally the studies demonstrated positive effects on team working abilities. In particular, qualitative evidence around these studies indicated that this training gave participants a better understanding of their colleagues' roles. This is important as it was identified as a barrier to good inter-professional working. However, again there is no evidence as to how this translates into clinical outcomes.

Due to the lack of good evidence on actions to improve inter-professional working, it is worth considering what staff perceive the barriers and facilitators to inter-professional working to be. Fifteen separate studies which were generally well conducted examined this across a range of countries.

Specifically, there needs to be opportunities for health professionals from different disciplines to regularly meet and discuss their clients together. In addition to providing collaborative care, this will also give health professionals a chance to understand each other's roles and competencies, get to know one another and develop trust. This will enable collaborative working when the women is receiving care from multiple providers and should potentially improve referral and risk escalation and de-escalation processes. This can potentially be further facilitated by regular contact in the workplace (including informal settings) and also through IPE, including throughout undergraduate learning.

Standardised approaches to improve communication, both in terms of records of women (whether women held or not) and babies (particularly at the interface of primary care and hospital care) and also when handing care over or in emergency situations (e.g. SBAR tool), could help make inter-professional working easier and reduce mistakes that may potentially lead to adverse outcomes.

Place of Birth

There is strong, high quality evidence to support the promotion of real choice to women about the location of their maternity care: through the antenatal, intrapartum and postnatal period.

High quality large scale observational studies of place of birth have demonstrated that midwifery care settings including home birth, freestanding midwifery units and alongside midwifery units, are a safe option for the majority of healthy women with uncomplicated pregnancies.

There appears to be a significant difference between the proportion of women that indicate in surveys that they would like to give birth at home or in midwifery units, compared to the very low proportion of women who currently give birth in these settings across Scotland.

Systems should be developed to support the provision of real choice in relation to place of care and birth, including evidence-based accessible information and decision aids for women, families and health professionals, appropriate physical settings to act as 'community hubs', the relocation of maternity professionals to reflect the shift from hospital centred to community centred care and the implementation of team systems that support the provision of community-based maternity care including intrapartum care.

Continuity Models of Care

There is strong high quality evidence to support the implementation of a model of maternity care that provides continuity of carer through the childbirth journey. Midwife-led continuity models of care have been found to have a range of benefits in relation to birth outcomes with no identified adverse outcomes. Where women require team care due to risk factors or complications, it is of benefit for them to also receive continuity of carer that enables them to build relationships with the health professionals providing their care. The desire for greater levels of continuity of carer comes across strongly in all surveys and consultations with maternity service users.



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