Maternity and neonatal care - Best Start five-year plan 2017–2024: report

Key Achievements: New Model of Care

Key Achievements: New Model of Care (Recommendations 1 – 42)

The Best Start made 42 recommendations for how Scotland’s new person-centred, safe and effective model of maternity and neonatal care should be set up. These recommendations were grouped under the following headings:

1. Continuity of carer

2. Person-centred maternity and neonatal care

3. Family-centred care

4. Multi-professional team working and pathways to care

5. Redesigned personalised care

6. Multi-professional working, culture and behaviours

7. New model of multi-professional working, culture and behaviours

8. Role of the third sector

9. Workforce implications

10. Accessible and appropriate local services

11. Community-based care and support staff - supporting infant feeding

12. Midwifery across the career framework

13. Equipping the workforce to deliver

14. Specialist services

15. Theatre and critical care (high dependency and intensive care)

16. Services for vulnerable women

17. Workforce and education

18. Perinatal mental health

19. Bereavement

The redesign of maternity and neonatal services is a multifaceted and challenging undertaking, requiring a change in the established approach to care. Work to take forward the recommendations has been led by all 14 of the Health Boards in Scotland, who have responsibility for the delivery of health services for their populations. Real changes for women and their babies have been introduced due to the innovative work in Boards.

National-level change was required to achieve some recommendations, which has been led by the Scottish Government and other national bodies.

A huge amount of work has taken place to meet the New Model of Care objective of the ‘Best Start.’ A selection of the key developments are provided below.

Continuity of Carer

Recommendation 1 of the Best Start is the introduction of continuity of carer in midwifery and obstetrics for all women, regardless of their individual circumstances or risk status. This is one of the most significant service redesign recommendations, requiring a revision of the way midwifery and obstetric care was generally provided. In a continuity of carer model, the woman’s primary midwife and/or secondary midwife (the buddy) or a member of the same team, will deliver all of her antenatal, intrapartum and postnatal care, and women who need the input of an obstetrician will have continuity of a primary obstetrician throughout their antenatal and postnatal care.

Evidence available at the time of the Strategic Review of Maternity and Neonatal Service and the publication of the Best Start indicated that continuity of carer improved outcomes for both mothers and babies, reduced levels of preterm birth, reduced levels of intervention, reduced neonatal mortality and improved experience of care, and increased breastfeeding.

In 2024 Cochrane published an update on their 2015 systematic review to include evidence up to 2022. It remains the case that the available evidence demonstrates that continuity of carer can improve maternal outcomes, and the Scottish Government continues to support implementation of the model.

The following reflects progress with the delivery of this recommendation.

• In 2017 five ‘Early Adopter’ Health Boards (EABs) were identified to pilot implementation of some Best Start recommendations, including continuity of midwifery carer and local delivery of care more broadly. The EABs were agreed by the IPB further to a process of selection from a large number of Boards who volunteered. Funding was allocated in 2017/18 to support planning for implementation, and in 2018/19 and 2019/20 to support the transitional work required for local service redesign.
• The Continuity of Carer and Local Delivery Subgroup (CCLD) carried out extensive work to develop clear definitions and measures for continuity of carer, including initiating discussions with BadgerNet (the digital maternity record) to support data capture.
• The new Nursing and Midwifery Council Future Midwife Standards, published in 2019, outlines proficiencies and educational preparation for midwifery going forward and has a key focus on continuity of carer.
• In 2020 a video about implementing Continuity of Carer across Scotland and sharing experiences of midwives, managers and women was created and shared on YouTube.
• The learning and experience of these EABs was compiled into the Continuity Of Carer And Local Delivery Of Care: Implementation Framework. The Implementation Framework was published in 2020 and designed to enable maternity services to access useful tools, resources and information to implement continuity of carer and local delivery of care, and track progress.
• In May 2022, following evidence from Mothers and Babies: Reducing Risk through Adults and Confidential Enquiries across the UK (MBRRACE-UK) showing that Black, Asian and minority ethnic women and families experiencing social complexities have poorer maternity outcomes, Boards were asked to prioritise delivering continuity of carer to these groups, while continuing to work towards offering continuity of carer to all women. This focused approach is now being delivered in the majority of Boards.
• 13 of 14 Health Boards reported that over 95% of women are allocated a primary midwife for pregnancy care in the period from October 2023 to March 2024.

Following a deep dive with the early adopter Boards in 2019, the target implementation date for continuity of carer was revised to mid-2026 to allow Boards more time to introduce the model.

Monitoring shows that there are different levels of implementation of continuity of carer in different areas, but the scale of the service redesign and impact of the Covid-19 pandemic on maternity services is an ongoing challenge. The progress of Health Boards towards full implementation will continue to be monitored until the target implementation date in mid-2026, and support provided as required. Evaluation of continuity of carer will be included in the evaluation programme for the ‘Best Start’.

Below is a selection of examples of local delivery of continuity of carer which illustrate some of the progress made by Health Boards.

• NHS Borders have improved the level of antenatal and postnatal continuity of midwifery care in the community setting. NHS Borders carried out a number of activities including a Women and Children’s services review, mapping of the pregnancy, labour and postnatal journey, scoping of options for care delivery, reviewing finance implications, holding staff information sessions and gathering service user feedback, and used the findings to shape their service so it works best for the women they care for. The results of improved continuity of carer had a positive impact beyond the maternity team, and has improved collaborative working with obstetric, neonatal/paediatric, mental health, Health Visiting, Social Work, and Prevention and Management of Aggression and Violence teams. The enthusiasm and dedication of their small team of midwives is reflected in the positive feedback their service users have given them. One mother, sharing her story on Care Opinion, said, “We had our third baby last month under the care of community midwives in Gala and Borders General Hospital. The level of care at every point in our journey has been exceptional… We made use of the “Thistle service” having had a previous traumatic experience, which was so helpful. It meant our story was known and we didn’t have to keep going over it...”
• NHS Forth Valley were one of the early adopter boards and have reformed their midwifery teams to provide continuity of carer to women in Forth Valley. A staged approach to the implementation of case loading was taken and the first two teams were in place by August 2018. A rolling programme of case loading teams followed and by January 2020 all women in Forth Valley booking for midwifery care were allocated a primary midwife from booking. Through trialling different shift patterns and on call systems, Forth Valley have established an effective system, with teams of midwives working both in community and inpatient areas. Forth Valley consistently report high rates of antenatal and postnatal continuity of carer, and rates of intrapartum continuity are increasing following recent recruitment.
• In NHS Highland, focus has been on improving antenatal and postnatal continuity of carer, with the midwifery leadership team introducing quality improvement workstreams, and employing a Best Start midwife to support the work. As well as antenatal and postnatal continuity of carer, for women who live in the remote and rural areas of Highland who have access to one of the 8 Community Midwifery Units, there is a level of continuity through the whole midwifery journey, including intrapartum care. Obstetric consultants are also allocated to teams across North Highland to promote continuity where possible, and there are named consultants from NHS GGC for Argyll and Bute. NHS Highland have worked to encourage recruitment of midwives in the area, with more staff leading to the ability to implement continuity of carer. More focused quality improvement workstreams are planned to continue the continuity journey.

There are also some ongoing challenges facing Boards as teams work to introduce continuity of carer whilst still delivering care to women. Staffing pressures, case load, skill mix and financial implications are frequently cited, and some examples have been provided by Health Boards.

• In NHS Lothian, more action planning is being done following an analysis of challenges related to improving postnatal continuity of carer. Lothian are seeing some good figures when reviewing their antenatal continuity of carer, delivered by the primary midwife and her buddy, reaching an average of 70% continuity across their 12 community midwifery teams between October 2023 and March 2024. Learning from pilot teams is helping inform a spectrum of plans that NHS Lothian are considering to increase provision of maternity continuity of carer across antenatal, intrapartum and postnatal care.
• Staffing is a challenge also reported by NHS Western Isles. The aim of allocating all women a primary midwife has been achieved, but challenges remain with implementing intrapartum continuity with a small workforce. NHS Western Isles are also exploring how best to achieve postnatal continuity with the staffing model they have, which is an integrated hospital and community service.

Progress Rating

As one of the most significant service redesign recommendations of the Best Start, work is still ongoing to introduce continuity of midwifery and obstetric carer across Scotland by the revised implementation deadline of mid-2026. Progress varies across Boards, but there are many examples of creative approaches to providing a continuity of carer service, particularly for midwifery care. Challenges remain, particularly with delivery of intrapartum continuity, however there is continued commitment to the introduction of continuity of carer at both the local and national level, and it has been included in the 2024/25 Programme for Government.

Recommendation 1

Continuity of Carer.

Rated: Green

Delivery: Local Delivery

Person-Centred Maternity and Neonatal Care and Family-Centred Care

Recommendations 2 – 10 focus on the vision of family-centred, compassionate care recognising the unique circumstances and preferences of mothers, their partners, and their babies. Below are some highlights related to these recommendations.

• There has been an increase in the number of women who have birth plans that reflect their choices and have input from neonatal and obstetric staff as required. Six Boards report that more than 90% of women have birth plans with evidence of multi-disciplinary input and two report this recommendation is completely embedded in their service. Two Boards report that 80% of women have multi-disciplinary birth plans in place. Four Boards report that between 39% and 75% of women have a multi-disciplinary birth plan in place.
• All 14 Boards have mechanisms to support communication and information sharing between midwives and health visitors, and 13 Boards have a mechanism for midwives and GP services.
• All Boards which provide neonatal care report that parents of babies in neonatal are involved in decisions about their care, consultant ward rounds, and in practical aspects of care including kangaroo skin-to-skin and breastfeeding.
• Considerable developments have been made to ensure mother and baby stay together and separation is minimised, including when the baby needs additional care. Of the 11 Boards which provide neonatal care, 10 report that they have now redesigned their maternity and neonatal services to minimise separation between mothers and babies.
• The Neonatal Expenses Fund (NEF) was launched by the Scottish Government on 1 April 2018 to help parents of babies in neonatal care to offset the cost of subsistence and travel to and from hospital during the early days of their baby’s life. In 2021 the Young Patient Family Fund (YPFF) was launched and was merged with the NEF to create a single unified fund for parents, primary carers and/or siblings (under 18) of the young inpatient (also aged under 18). The fund also encompasses fathers’ or partners’ visits to newborns while the mother receives treatment, if they have at least one overnight stay in hospital. In 2023-24 eligible families of 3,613 young inpatients received support worth £2,923,657 from the fund.
• 13 Boards have accommodation to ensure that families can stay together, and partners are encouraged to stay. In the 14th Board, cot side relaxer chairs are being purchased to facilitate this. Boards have put in place mechanisms for gathering feedback from service users on this, so they can respond to the needs of their populations.
• For parents of babies in neonatal facilities, emergency accommodation is offered. Two Boards have reported that availability can be a challenge. One of these is seeking alternative offsite accommodation options and another has refurbished a room for families within the neonatal facility to facilitate families spending time together. In addition, accommodation is part of Boards’ planning for delivery of the new model of neonatal intensive care (Recommendation 45).
• The Best Start recommended that high-quality antenatal education must be available to all, and that Boards should promote and improve early access. Whilst antenatal education was provided by Boards before the ‘Best Start’, the focus on quality antenatal education is now embedded in ‘business as usual’ delivery for Boards. As part of the recommendation, Boards were asked to carry out a stock take of the antenatal education they provide and audit feedback from attendees. The restrictions on face-to-face services during the pandemic led to an increase in the amount of education provided through online platforms. The majority of Boards report that service user feedback indicates a preference for face-to-face education, and the majority have returned, partially or fully, to offering face-to-face classes. All Boards report that they are piloting or delivering one-to-one services for women with socially complex needs.
• The Best Start recommended that ‘Ready, Steady, Baby!’ resources were redesigned to reflect the new model of care. This was done at a national level, and the resources, which are hosted by Public Health Scotland (PHS), continue to be regularly revised to ensure they are up to date. The resources continue to be distributed free of charge to every pregnant woman in Scotland through midwives at their antenatal booking appointment, to build on the advice given by health professionals. The Ready Steady Baby! booklets are available as webpages on NHS Inform. ‘Ready Steady Baby!’ also includes information about third sector organisations and services which can provide additional support or advice, including on matters such as money advice and housing rights.
• In 2021, the Scottish Government commissioned the Scottish Perinatal Network (SPN) to coproduce, with a wide range of stakeholders, a model for engaging maternity service users that is consistent across Scotland. Following extensive collaboration with maternity and engagement professionals within Boards, and user-testing with over 300 service users, the new Scottish Maternity Engagement Framework was published on the SPN website in September 2024. Further work to support Boards with implementing the Framework to enhance their existing maternity and neonatal service user engagement approaches will continue beyond the end of the Best Start programme.

Health Boards have provided some examples of how they have successfully implemented these Best Start recommendations; below is a small selection of examples.

• In 2018, a transitional care unit (TCU) was introduced by NHS Lanarkshire, who created a dedicated transitional care ward which meets British Association of Perinatal Medicine (BAPM) recommendations. Babies with care requirements in excess of normal newborn care who meet the inclusion criteria can be cared for on this ward, which provides single rooms so families can stay together. There has been a positive reaction to the TCU – one mother, sharing her story on Care Opinion, wrote, ‘Our twin boys were planned CS at 34 weeks. I met Mary beforehand who explained the boys would be in the TCU ward with me after the CS. This was because they would need extra monitoring. The CS was fine and, after recovery, me and my partner spent the next 10 days together with our boys. The facilities are outstanding; the care is second to none. Being with the boys after birth was amazing, we thought they would go straight to the neonatal unit. Thank you to all the doctors, nurses and midwives for their compassionate care. We are home and missing the tea!’
• Following feedback from women, NHS Shetland have reintroduced their face-to-face antenatal education classes, which were moved online due to the Covid-19 pandemic. A group of midwives, a health visitor and a healthcare support worker received training from the Scottish Multi-Professional Maternity Development Programme, and monthly all-day sessions were then reintroduced. The sessions are always fully subscribed, and the health visitor who delivers the training won an award at the recent ‘Excellence in Care Awards’ with her presentation ‘Knowledge is power. Why antenatal education matters.’
• NHS Tayside has transformed how they deliver antenatal education for their women, beginning a programme of improvement work with the aim of increasing take-up of antenatal education and improving outcomes for women, partners and babies. Following surveys of midwives and service users to understand what is needed, NHS Tayside provided formal training for midwives and reformed the antenatal education provision available. NHS Tayside introduced an online parent education programme for those who prefer to learn online, and midwives began providing face-to-face sessions for the women on their caseload. This has been warmly received, with one woman providing feedback that she “Loved that my midwife took the classes and I feel like I know her so well – good fun and relaxed. My partner was worried about coming along but actually really enjoyed them and because he works away this is 1st time he had met my midwife so that was good. Loved the labour and birth best. Hopefully it will help me when the time comes.”

Midwives have also been providing bespoke sessions within the Dundee International Women’s Centre for women who do not have English as a first language. This group includes those who are seeking refugee and asylum. Midwives also provide sessions within women’s homes as appropriate, for example women with learning support needs, social anxiety, complex social issues, and one-to-one sessions are regularly facilitated by the specialist midwife for women who use substances/alcohol.

NHS Tayside are continuing to add more offerings for their women and have seen a considerable improvement in the number of women taking part in the antenatal education on offer.

Progress Rating

All nine recommendations made under the Person-Centered Maternity and Neonatal Care and Family-Centred Care subheadings of the Best Start have been completed. Recommendation 7 is pertinent to the introduction of the new model of neonatal intensive care (Recommendation 45), and the provision of accommodation under the new model is being considered by Boards.

Recommendation 2

Birth Plans are developed and updated.

Rated: Blue

Delivery: Local Delivery

Recommendation 3

Link GP is nominated by GP practices.

Rated: Blue

Delivery: Local Delivery

Recommendation 4

Parents of babies in neonatal care are involvedin decisions and care.

Rated: Blue

Delivery: Local Delivery

Recommendation 5

Services are redesigned to ensure mothers and babies stay together.

Rated: Blue

Delivery: Local Delivery

Recommendation 6

Families can stay together.

Rated: Blue

Delivery: Local Delivery

Recommendation 7

Neonatal facilities provide emergency overnight accommodation.

Rated: Blue

Delivery: Local Delivery

Recommendation 8

A nationally agreed policy on expenses for families of babies in neonatal care is put in place.

Rated: Blue

Delivery: National Delivery

Recommendation 9

High quality prenatal and antenatal education is available to all.

Rated: Blue

Delivery: Local Delivery

Recommendation 10

Redesign of Ready Steady Baby! reflects the new model of care.

Rated: Blue

Delivery: National Delivery

Multi-Professional Working and Pathways of Care

Recommendations 11-13 focus on delivering the best care to women and their babies through effective communication, team working and trust. This underpins the new model of person-centred care that Best Start presents, and the vision for multi-disciplinary care and training centred around the needs of the woman and her baby. Below are some of the key developments in this area.

• The 2009 NHS QIS Pathways for Maternity Care were revised by the Pathways working group, one of the working groups set up to report to the IPB, which began work in 2019. An evidence review was commissioned in 2019 to inform the revision process. The work was paused during the Covid-19 pandemic and resumed in 2022. Following further work by the Pathways working group and consultation with the clinical community, the revised Pathway of Maternity Care was published on 13 February 2025, which provides national guidance on clinical expectations at scheduled visits and an accompanying schedule.
• Recommendation 12 was that Boards ensure they have high-performing, multi-professional teams who are developed and supported to operate effectively and have multi-professional team training opportunities. In April 2024, all Boards reported that they had completed this recommendation or that they were on track to complete it by the target implementation date of mid-2024. The four measures of this recommendation that are monitored are core mandatory training requirements, shared access to records and clinical information, provision of forums for multi-disciplinary teams, and multi-disciplinary leadership training. Boards have reported examples of good practice including postnatal incident debriefs with service users offered with a multi-disciplinary team approach, and the establishment of regular multi-disciplinary professional updates and touch points.
• National networks set up under the Best Start have fostered a culture of collaboration and joined-up working across maternity and neonatal services. The National Neonatal Network and National Maternity Network were set up in 2019 and 2020, initially as separate networks for neonatal and maternity, but now function as a single perinatal network and are managed together as the SPN. Further information can be found in the section about Recommendations 73 and 74.

NHS Ayrshire and Arran have transformed their practice development provision. Following success of a project with the Maternity Practice development team, a Women and Children’s services practice development team that encompasses all services and staff within the directorate has been introduced. Proactive training is provided and includes use of digital platforms. This way of working across clinical disciplines has improved team working and understanding of services within the directorate.

Progress Rating

Two of the three recommendations on Multi-Professional Working and Pathways of Care have been completed, and the revised Pathway of Maternity Care has been published. As it was published after the original deadline of mid-2024 but before the publication of this report, it has been included but rated green as Boards will now introduce it across their services. It underpins the individualised model of care which is delivered by a cohesive, multi-professional team who work together to meet the needs of women, babies and their families.

Recommendation 11

The 2009 Pathways for Maternity Care should be revised at a national level.

Rated: Green*

*Published after June 2024 but prior to publication of this report.

Delivery: National Delivery

Recommendation 12

High-performing, multi-professional teams are developed and supported to operate effectively.

Rated: Blue

Delivery: Local Delivery

Recommendation 13

A directory of third sector services, available to maternity and neonatal service users, should be created.

Rated: Blue

Delivery: National Delivery

Accessible and Appropriate Local Services

Recommendations 14 - 23 promote the provision of access to routine care as close to home as possible and is one of the cornerstones of the Best Start, while acknowledging that in some circumstances, where specialist care is needed, some travel may be needed.

The Best Start set out a number of recommendations on how accessible and appropriate local services should be provided, including multi-disciplinary community hubs, choice of place of birth, type of birth and pain relief options, early discharge, high-quality postnatal care, transitional care and routine examination of the newborn. Below are some highlights related to these recommendations.

Recommendations for Local Delivery

• The Best Start recommended that NHS Boards should redesign maternity services with a focus on local care, built around the concept of multi-disciplinary community hubs. Local multi-disciplinary community hubs were described in the Best Start as places where women can receive routine care and services in a convenient location close to home. Implementation of this recommendation has required considerable scoping and redesign of service provision by Boards, who have undertaken assessments of the services that could be offered in a community hub in their area. In total, Boards report to be operating 60 community hubs or pilots (ranging from 0 to 15). Of the five Boards who report having no hubs, three are Island Boards who instead offer care through home visits, at hospital, or via telemedicine service Near Me – a service-user facing video consulting platform. Some of the challenges with introducing community hubs include being unable to reach a critical mass of service users (particularly for Island Boards), access to suitable accommodation, funding to bring accommodation to the necessary standard and staffing.

The remaining nine Boards have set up hubs delivering a range of services, including antenatal care, scanning, screening, sexual health, vaccination and parenting education. Some community hubs have been located in hospitals, GP surgeries, and Health and Social Care Partnership buildings. This means that midwives can work alongside other services, with examples from one Board including social work, psychological services, health visiting and physiotherapy. Implementation of the recommendation to introduce community hubs will continue, as the Best Start model of care is now embedded in maternity services as ‘business as usual’.

• Health Boards were asked to ensure that they could provide a full range of choice of place of birth: hospital birth (obstetric unit), alongside midwifery unit or community midwifery unit, and home birth. To meet this recommendation, some Boards have established new alongside midwifery units, some have been refurbished, and a number of Boards have focused on increasing their home birth rate. Boards are advertising the choice of place of birth in their area via websites and social media to raise awareness of the different options women have. Whilst all Boards have obstetric units, some Boards have challenges with estate availability and capacity of teams which has limited their ability to offer the full range of choice. Data collection systems used across Scotland currently do not permit reliable collection of place of birth data, which limits understandingof where women are choosing to give birth at a national level.
• The Best Start recommended that Boards should aim to provide a range of natural pain relief and comfort options for women. All Boards report that this is complete or mostly complete. Four Boards report that surveys of women were ongoing into mid-2024. To ensure that service development and provisions meet women’s needs, Boards were asked to seek feedback from women on their maternity experiences. Boards have reported improvements to the equipment and rooms available to try and offer a welcoming environment. For example, one Board has used Best Start funding to purchase equipment to support upright and active birth while another has introduced soft lighting and welcome boards and sought feedback of women who used their services on how they found the environment.
• Early transfer to community postnatal care has been embedded as normal practice in a number of Boards, in line with the Best Start recommendation that, in routine circumstances, families should be encouraged to go home as soon as possible following birth. 13 Boards report that they have a discharge policy, principles, or guidance which support this, and work is underway in the remaining Board. While these are in place, two Boards report that challenges remain with implementing early discharge home for reasons including access to patient transport and availability of medical staff to complete the medical review if required, and other birth-related factors (including rising rate of Caesarean births and clinical conditions) increasing the length of stay required.
• Neonatal transitional care is being offered in 12 Health Boards. One Island Board does not provide neonatal care, and another reports that estate challenges mean it cannot be provided. Some Health Boards that do offer it have dedicated transitional care wards, while in some transitional care is provided on the maternity, postnatal or neonatal ward.

Recommendations for National Delivery

• Place of birth should be discussed early in antenatal care and revisited throughout pregnancy, recorded in the birth plan, and updated as required if the woman’s decision changes during her pregnancy. To meet the Best Start recommendation that national, standardised core information is provided to women to help them make this decision, a new leaflet for women on choice of place of birth has been developed by the Scottish Government in collaboration with the Pathways working group. The Birthplace Decisions Leaflet was published on 13 February 2025.
• The Best Start recommended that Caesarean birth should only be provided if clinically indicated, and factors contributing toward the rising rate be examined and optimal levels of intervention identified. The terms ‘Caesarean section’ and ‘Caesarean delivery’ were used in the original drafting of Recommendation 17, however the term ‘Caesarean birth’ is now the preferred term for this type of birth.¹ A review of rising rates of Caesarean delivery was undertaken and published by the Scottish Government in 2021. Following this, Healthcare Improvement Scotland (HIS), as part of the Scottish Patient Safety Perinatal Programme developed a programme of work focused on understanding variation in Caesarean birth. The SPSP Caesarean Birth Change Package was published in 2023 to support teams in understanding variation in Caesarean births across the NHS Scotland, to inform improvement priorities and support informed choice.
• The introduction of the Health and Care (Staffing) (Scotland) Act 2019 will support the implementation of Recommendation 21, which sets out that postnatal care should be afforded a high priority, with staffing models reviewed in conjunction with the introduction of continuity of carer. The legislation places a duty on those who provide care services to ensure both appropriate staffing and appropriate training of staff. The delivery of this recommendation is linked to Recommendation 64, on workforce planning.
• Recommendation 23 of the Best Start was that routine examination of the newborn can, in most cases, be undertaken by appropriately trained midwifery staff, with an appropriate audit and governance mechanism in place to evaluate the outcome. The Workforce and Education Subgroup initially led work on this recommendation, and in 2018 produced a Framework for the Examination of the Newborn Training and Governance. Work then transferred to be led nationally by Scottish Government and HIS. Work is ongoing to establish audit and governance processes beyond those which already operate within Health Boards, and a training programme is in place. Through the Scottish Multi-Professional Maternity Development Programme (SMMDP), NHS Education for Scotland (NES) provides the Scottish Routine Examination of the Newborn Course (SRENC). SRENC provides candidates with the opportunity to acquire the skills and knowledge to undertake the routine examination of the newborn.

There are many examples of work done to meet these recommendations by Health Boards across Scotland. Some examples are provided below.

• Home birth rates have increased from 0.2% to 2.8% in NHS Ayrshire and Arran following the introduction of a new Home Birth team who provide care for women and families requesting a birth at home. In May 2019, the team was set up and was fully staffed by 2020. Some achievements of the team include delivering individualised antenatal education, hosting ‘meet the team’ days for members of the public, changing the on-call provision following review to better suit staff availability, ongoing additional skills training, and achieving a 2.8% home birth rate, 0.8% higher than the improvement target.

• NHS Orkney has introduced new criteria and pathways to reduce the number of women transferred to the mainland to give birth or attend routine appointments, in line with feedback from women. Multi-disciplinary teams worked together to set up services to support women to stay in the local maternity unit, including Vaginal Birth after Caesarean, Induction and Augmentation of Labour, and local diabetes clinics. For women with more complex needs, NHS Orkney and NHS Grampian have worked together to increase the use of Near Me so women can remain at home for routine appointments. Birth data indicates that transfer rate has reduced from 30.7% in 2018/19 to a current rate for the first quarter of 2024 of 22.9%. NHS Orkney has also increased access to non-pharmaceutical pain relief options, including through a new birthing pool, hypnobirthing training and aromatherapy. The team have received positive feedback from service users, including a mother who has two children at home already, who said, “The thought of experiencing this labour in Aberdeen where [husband’s name] wouldn’t have been able to stay with me so long (and overnight) following the birth is dreadful… We are incredibly lucky to have such an amazing team in Orkney who truly make each Mum’s experience a very personal one.’
• NHS Tayside has been exploring options for introducing more community hubs in Dundee City, Angus, and Perth and Kinross, and are managing challenges with accommodation allocation and funding to bring it up to the necessary standard. Following a scoping exercise, the team identified the number of hubs they need and which services they should host. Care is currently provided in hospital sites, Health and Social Care Partnership accommodation, through home appointments and two freestanding community midwifery units. Some accommodation options have been identified and are currently being set up, and the team is taking a flexible approach to what can reasonably be provided and where. Links are being made with other services working from the same locations, including the infant mental health team who are co-located with the midwifery continuity team in one of the Dundee hubs.
• NHS Forth Valley introduced a transitional care unit, and as a result have seen a reduction in their admission to the neonatal unit (72% reduction in March 2024). Forth Valley took a collaborative approach to the process, hosting staff engagement sessions to share ideas and identify training needs so clinical skills could be updated. Feedback from parents on this new service has been positive, with one parent commenting that: “Transitional care has been a very positive experience for me and extremely beneficial to me and my family. [Dad] has felt very supported due to the care that I have had in helping to look after our child.”
• NHS Greater Glasgow and Clyde - until 2023, women living in Glasgow only had access to homebirth and consultant-led-unit intrapartum care, and did not have the option to receive their intrapartum care from their midwives in a community or hospital setting, as women living in Clyde did. To address this, NHS Greater Glasgow and Clyde began work to open new Alongside Midwifery Units (AMUs) at the Queen Elizabeth University Hospital and the Princess Royal Maternity Hospital. As well as offering greater choice for place of birth, the project aims to improve midwives’ confidence and skills in physiological labour and care, and reduce unnecessary interventions. NHS GGC employed two project midwives to lead this work. They established a multi-disciplinary group to shape and oversee development of the new units, visited other AMUs in Scotland to learn about what has worked well, and worked with women to co-design the style of the rooms to ensure they were spaces women would want to use. The project midwives also provided staff with guidance and education workshops to equip them with the skills they needed to use the new AMUs. The AMUs opened in May 2023. NHS GGC data shows that birth outcomes were similar in the AMU and obstetric-led unit (OLU), but there was a slightly higher rate of assisted births and intervention in low-risk women admitted to the OLU compared to the AMU.

Feedback from women has also been very positive. A survey carried out reported that 90% of women that were admitted to the AMU had a positive birth experience, with 70% of women who had given birth before reporting it was better than their last experience. One woman who gave birth there said:

“I honestly think the birth room was so perfect. I still get goosebumps when I talk about my son’s birth because it was so incredible and empowering. The room was beautiful and was so lovely to spend time there after he was born, it felt so homely. I was only in labour for 2 hours with my son, the midwives were incredible. Loved the lighting etc., honestly I think these rooms should win an award. Your team should be really proud of them.”

Progress Rating

Seven recommendations on Accessible and Appropriate Local Services have been completed, two are green and two are amber. Documents have been published to meet the two recommendations that are green (SPSP Caesarean Birth Change Package and the Birthplace Decisions leaflet) and are with the system now for implementation.

Recommendation 21 will be met through workforce planning processes which are being introduced to meet the requirements of the Health and Care (Staffing) (Scotland) Act 2019, including the Real-Time Staffing Resource launched in February 2024, and the ongoing digitalisation of the Maternity-specific Real-Time Staffing Resource which is being led by HIS. Recommendation 64 provides more information about this work.

Recommendation 23 is rated amber as work continues to establish national-level audit and governance processes, in addition to existing local mechanisms. Alignment with wider-ranging maternity standards work being led by HIS is being considered.

Recommendation 14

NHS Boards should redesign maternity services with a focus on local care, built around the concept of multi-disciplinary community hubs.

Rated: Blue

Delivery: Local Delivery

Recommendation 15a

Full range of choice of place of birth.

Rated: Blue

Delivery: Local Delivery

Recommendation 15b

National, standardised core information should be made available on the range of safe birth settings.

Rated: Green*

*Published after June 2024 but prior to publication of this report.

Delivery: National Delivery

Recommendation 16

Boards should aim to provide a range of pain relief.

Rated: Blue

Delivery: Local Delivery

Recommendation 17

Caesarean delivery should only be provided if clinically indicated and factors contributing to the rising Caesarean section rate should be examined.

Rated: Green

Delivery: National Delivery

Recommendation 18

Boards should undertake an assessment of the viability, and scope, of freestanding midwifery units.

Rated: Blue

Delivery: Local Delivery

Recommendation 19

Options for postnatal care should be discussed with women throughout pregnancy and a plan agreed which takes account of their unique circumstances.

Rated: Blue

Delivery: Local Delivery

Recommendation 20

Key processes should be aligned and streamlined to ensure early discharge is the norm.

Rated: Blue

Delivery: Local Delivery

Recommendation 21

High-quality postnatal care should be high priority, with staffing models reviewed in conjunction with the introduction of the continuity of carer model.

Rated: Amber

Delivery: National Delivery

Recommendation 22

Well, late preterm infants and term infants with moderate additional care needs remain with their mothers and have their additional care needs provided on a postnatal ward.

Rated: Blue

Delivery: Local Delivery

Recommendation 23

Routine examination of the newborn undertaken by appropriately trained midwifery staff, with an appropriate audit and governance mechanism in place.

Rated: Amber

Delivery: National Delivery

Community-Based Care and Support Staff - Supporting Infant Feeding

Recommendation 24 of the Best Start was that continuity of carer, community hubs and enhanced community care provide an environment to support breastfeeding. Community-based care should include a role for support staff to assist midwives in the provision of baby care, including breastfeeding support and parenting skills, along with care and support for women who formula feed.

NHS Education for Scotland (NES) led on delivery of this action. A summary of the work carried out to date includes.

• in 2018, the establishment of a Short Life Working Group to explore the key competencies and skills required for remote and rural practice. A national Maternity Health Care Support Workers (HCSWs) Learning Survey was conducted in 2018 and the report published in April 2019. Although it was a generic survey for all clinical disciplines, it provided useful insights on which to build for the maternity workforce.
• in 2019, a masterclass approach piloted by NES and NHS Grampian, to clarify support worker roles and unlock their potential.
• a scoping project ‘Investigating the future role of maternity support workers in Continuity of Carer Models’, which was conducted by NES in 2021. This project identified several recommendations that align with the recent work of developing a bespoke career and education framework for Perinatal HCSWs, i.e., those working in maternity and neonatal settings or a combination of both (transitional care).
• in response to recommendations identified by the project, masterclasses for HCSWs facilitated by NES. NES have also promoted personal development discussions between support workers and managers, and developed the Perinatal HCSW L2-4 Framework. The framework provides guidance for maternity and neonatal HCSW roles and is now available.
• a clinical skills workbook to support non-registered staff across all hospital and community settings in relation to breastfeeding knowledge, which is being developed by NES’s Senior Educator for Infant Feeding.

Progress Rating

• The Best Start set out that breastfeeding should be supported by the new model of care, and good progress has been made by the Short Life Working Group and NES to meet this recommendation. The Perinatal HCSW L2-4 Framework will support the workforce, meeting the recommendation that support staff play a role in the provision of baby care.

Recommendation 24

Continuity of carer, community hubs and enhanced community care provide an environment to support breastfeeding. Community-based care will include a role for support staff to assist midwives in the provision of baby care, including breastfeeding support and parenting skills, along with care and support for women who formula feed.

Rated: Green

Delivery: National Delivery

Midwifery Across the Career Framework and Equipping the Workforce to Deliver

Recommendations 25 – 27 support the role of midwives in the new model of maternity and neonatal care, focusing on ongoing training in core skills, development of clinical midwifery roles and development of a staffing profile to support the new model of postnatal neonatal care and transitional care. The phrase ‘normal birth’ was used in recommendation 25 when it was originally drafted; however, the term ‘spontaneous vaginal birth’ is now the preferred term for this type of birth.² Work has been led by NES and Health Boards, and some key achievements are summarised below.

• Recommendations 24-26 build upon and are linked to the existing registration development framework contained within the Career Framework (scot.nhs.uk).
• NES offer the Scottish Multi-Professional Maternity Development Programme courses, which cover core maternity and neonatal training, including neonatal examination. Additionally, NES delivers educational provision to support the Best Start recommendations across the entire workforce. This additional training offer includes:
  • managing caseloads and making effective clinical decisions.
  • birth in the community.
  • neonatal transitional care.
  • building a therapeutic relationship.
  • OASIS and perineal repair.
  • waterbirth.
  • managing obstetric emergencies in the home setting.
  • NES are leading a package of ongoing work on the midwifery career framework:
  • the Midwifery Workforce and Education review, which was published in 2021. The report recommended a national midwifery career framework, supported by an education framework, be published. Though a separate review, this aligns with Recommendation 26 of the Best Start. There is ongoing development work being taken forward under a national steering group.
  • in cooperation with this national steering group, the Midwifery Preceptorship Framework for Scotland was published in 2023, and outlines the support required for newly registered midwives, those returning to practice and those new to role (including internationally recruited midwives).
  • Five pathfinder Boards led roll-out of the Preceptorship Framework, and a formal evaluation of the implementation of the framework was published on NHS Scotland’s Turas website in November 2024.
  • NES have developed the Perinatal HCSW L2-4 Framework, which also supports this work. Work continued throughout 2024 to complete this component, which was informed by work being undertaken by the RCM to refresh their midwifery career framework. The framework is available and NES will move to Level 5-9 in due course.

Progress Rating

Two of the three recommendations under the Midwifery Across the Career Framework and Equipping the Workforce to Deliver subheadings of the Best Start have been completed. The Perinatal HCSW L2-4 Framework has been published and will support implementation of Recommendation 26.Ongoing work to implement the Midwifery Workforce and Education review and future work on a HCSW Level 5-9 Framework will also contribute towards completion of this recommendation.

Recommendation 25

Midwifery refresher education and training in core skills including supporting normal birth processes and providing care across the whole care continuum, and in examination of the newborn.

Rated: Blue

Delivery: National Delivery

Recommendation 26

Development of clinical midwifery roles across the career framework as part of national work to transform nursing, midwifery and allied health professional roles.

Rated: Green

Delivery: National Delivery

Recommendation 27

Revised staffing profile for inpatient postnatal maternal and neonatal care should be developed collaboratively by maternity and neonatal care providers, underpinned by staff education and training in relation to postnatal maternal and neonatal care.

Rated: Blue

Delivery: Local Delivery

Specialist Services

A small number of women with the most complex care needs will need to access highly specialist care for themselves (maternal medicine), or their baby (fetal medicine), or both. The Best Start gave four recommendations (28 – 31) on specialist services.

The SPN is a Strategic Network, commissioned by the Scottish Government, which facilitates collaboration across maternity and neonatal services and coordinates working groups around priorities identified by the perinatal clinical community and strategic partners. More information can be found in the section about managed clinical networks.

Together with the 14 territorial Health Boards, the SPN led on work to meet the recommendations in the Best Start report related to specialist maternity care, maternal medicine, including presentation to acute hospital settings, and fetal medicine. Some of this work is ongoing.

• The Obstetric Neurology Group produced guidelines on the management of headache and epilepsy in pregnancy, originally working under direct Best Start governance. The draft guidance was adopted by the SPN in 2022 for peer review, publication and future governance. The two guidelines were published in February 2023, following clinical peer review and consultation.
• The Best Start Maternal Medicine Group was set up before the Covid-19 pandemic and moved to SPN oversight in 2023. A first meeting of the reconvened group with refreshed membership was held in September 2023. A work plan is now in place to:
  • develop national guidance on the initial management of suspected ischaemic stroke in pregnancy. This work is ongoing, building on locally developed NHS Lothian guidance which is being adapted to scale up for national application.
  • work with NES to develop Scottish Acute Maternal Medicine Fellowship / Credentials courses.
  • map specialist pregnancy clinics for acutely unwell women.
  • assess the potential and practicalities to run simulation Managing Medical Obstetric Emergencies and Trauma (mMOET) style courses.
  • in December 2024 the Maternal Medicine Group published Guidance on Management of Diabetic Ketoacidosis (DKA) in Pregnancy in partnership with the Scottish Diabetes Group.
• All Health Boards have confirmed that each unit has identified a lead obstetrician who has appropriate expertise in fetal medicine.
• The Best Start Fetal Medicine group has transitioned to SPN, and work is underway to establish a work programme based on clinical priorities.

Progress Rating

The Best Start made four recommendations for Specialist Services, and Recommendation 30 has been divided into two parts for clearer reporting.

One recommendation is complete, one is rated green, and Recommendations 29, 30b and 31 are rated amber.

Recommendation 28 has been rated green as guidance on DKA, headache and epilepsy have been published by the SPN Maternal Medicine Group, and a guideline on suspected ischaemic stroke is underway. Recommendation 29 is rated amber but is within the remit of the SPN Maternal Medicine Group.

Recommendation 30b and 31 are rated amber and will be under consideration of the Fetal Medicine Group, which has recently transitioned to the SPN. The group will be reconvened and a work programme re-established.

Recommendation 28

Specialised medical input provided in a timely manner from an identified and named physician in that medical speciality, with an interest in pregnancy, and may need to be managed at a regional or national level.

Midwifery care should continue throughout from the primary midwife, as part of the multi-disciplinary team. Units providing the most specialised maternity and neonatal care should be co-located.

Rated: Green

Delivery: National Delivery

Recommendation 29

Where women present outwith maternity settings they should be reviewed by the maternity team in a timely manner to ensure pregnancy-appropriate medical care occurs at all times, in all locations. Standards for this should be agreed nationally.

Rated: Amber

Delivery: National Delivery

Recommendation 30a

Each unit must identify a lead obstetrician who has or who will develop appropriate expertise in fetal medicine.

Rated: Blue

Delivery: Local Delivery

Recommendation 30b

Good ongoing communication with and information for parents and robust referral pathways in each Board to ensure strong links between local and regional/national centres.

Rated: Amber

Delivery: National Delivery

Recommendation 31

Standardised information leaflets are given to parents during antenatal discussions on fetal abnormality.

Rated: Amber

Delivery: National Delivery

Theatre and Critical Care

Recommendations 32 and 33 relate to theatre and critical care and were based on evidence that the demographics and complexity of childbearing women has changed with time, resulting in an increased need for high dependency or intensive care, high dependency and critical care.

Since the evidence was reviewed in 2017, health profiles of pregnant women giving birth have changed again. In 2017/18, the percentage of women at antenatal booking with a Body Mass Index (BMI) indicating they were overweight or obese was 28.1% and 24.3% respectively. In 2023/24, this had increased to 29.3% and 27.7% respectively. Evidence demonstrates links between high maternal BMI and the risk of adverse pregnancy and delivery outcomes. In addition, data from PHS shows that, in keeping with maternal obesity trends, rates of diabetes in pregnancy have been increasing rapidly in recent years.

Implementation of Recommendations 32 and 33 have resulted in the following progress:

• 13 Health Boards provide critical care (theatre, high dependency or recovery). All have confirmed they now have dedicated staff, appropriately trained to the nationally agreed standards, who maintain relevant competencies to provide the same standard of care as received by the non-pregnant surgical patient.
• Boards also report that some staff have been upskilled through REACT programme, Practical Obstetric Multi-Professional (PROMPT) training, Core Competency Framework for Anaesthetic Practitioners, and maternal critical care modules through higher education providers.
• It was recommended by Best Start that maternity theatres should have dedicated staff. 11 Boards have completed this recommendation, and 2 others report that staffing is being addressed through either recruitment and training, or wider NHS Board workplans. One Island Board reports that theatres are a generalist provision supported by the theatre nursing team and not dedicated to maternity care.

Moreover, there are many examples of good practice locally:

NHS Fife has provided additional training to their Obstetric and Midwifery team, who provide enhanced maternity care to women (Level 0-2) and step down from critical care (Levels 2 and 3). A half-day, face-to-face, interactive course for Caring for the Critically ill Pregnant or Postpartum (CiPP) woman was developed and has been delivered to Agenda for Change Band 6 midwifery staff within the Obstetric Observation Area. This is led by an Obstetric and Anaesthetic Consultant as well as Senior Charge midwifery staff. Staff reported that they enjoyed the practical scenarios and presentations and have increased confidence and knowledge for treating critically ill women.

In NHS Lothian, the High-Risk lead has developed a formalised High Dependency course, in collaboration with midwifery staff, medical staff and the Clinical Education Department. Two cohorts of midwives have been trained in this competency-based training at the Simpson’s Centre for Reproductive Health (SCRH) and St. John’s Hospital (SJH). This training is helping NHS Lothian ensure rosters comply with the standard of having a high dependency midwife on every shift, which has been met at SCRH and is being worked towards at SJH.

Progress Rating

The Best Start acknowledged that the clinical complexities of childbearing women have changed, and made two recommendations to reflect that there is increased need for high dependency and intensive care. Both recommendations have been completed by Boards, who have implemented them in line with local need.

Recommendation 32

Staff providing critical care in theatre, recovery or high dependency must comply with national standards, be appropriately trained and regularly maintain competencies. Adequate staffing levels must be in place.

Rated: Blue

Delivery: Local Delivery

Recommendation 33

Maternity theatres should have dedicated theatre staffing, and these staff should be appropriately educated, trained and managed.

Rated: Blue

Delivery: Local Delivery

Service for Vulnerable Women

The Best Start included three recommendations on the delivery of maternity care for ‘vulnerable women’ (Recommendations 34 – 36). Since 2017, there has been a shift in the terminology used to describe women who experience medical, social and/or psychological complexities, taking a more person-centred approach, recognising that women are not inherently vulnerable, but may have factors in their lives which mean they would benefit from additional support.

Pregnancy is an opportunity to engage with women, some of whom may be interacting with public services for the first time, and work with them to improve outcomes for themselves and their babies. The Best Start recommendations focus on the provision of compassionate care which brings all the support a woman may need around her, including health and other services such as financial and housing advice. It also recommends that staff receive education and training so they are equipped to support women who would benefit from additional support. Health Boards have taken a number of actions to meet the recommendations.

• Boards report it is at the first booking appointment that midwives make routine enquiries with all women to understand their circumstances, and many have a specific tool for carrying out these assessments (for example, a Keeping Children Safe and Well Tool). Referral pathways are then used to engage the necessary additional support from other professionals.
• Systematic needs assessments have been carried out, or are planned, by some Boards to assess the level of need of their population. Improvement works in response to these include, for example, the development of specialised midwifery teams, and work to introduce complex social factor champions.
• A number of Boards have specially trained midwives or teams of midwives who deliver care for women with more complex circumstances, while in some areas midwives are supported by other professionals, such as nurses with additional responsibilities around social factors. Examples of training provided to staff to help them support pregnant women with additional care needs include Child Protection training, Routine Inquiry training, Trauma-Informed training and Gender-Based Violence training, amongst many others.
• Boards were asked to prioritising introducing continuity of carer for women experiencing social complexity and/or women with poorer maternity outcomes (e.g. Black, Asian, minority ethnic women). 11 Boards now have a process in place for identifying and offer continuity of carer to some or all of these women in their populations.
• All Boards report that staff can access additional training to help them support women with a range of needs.

Many Boards have examples of good practice in this area. A selection of examples is provided below:

In NHS Grampian, a specialist team called the Unity Team has been set up to provide care for women experiencing complexities. The team includes a specialist midwife for substance misuse, a specialist midwife for public protection, a specialist midwife for perinatal, and a Band 6 midwife. The team also provide training to other midwives, so they can identify and support women in their care.

NHS Greater Glasgow and Clyde’s Blossom team cares for women with social complexities, but all midwifery staff are able to access training in relation to improving care of women with additional care needs and social complexity. To support the Blossom midwives, they receive clinical supervision by the public protection midwife. NHS GGC are also looking at how to make sure women feel able to disclose alcohol and drug use and other issues associated with stigma, and help midwives identify when these issues are present. The development of longer appointments, training on Alcohol Brief Interventions for all community midwives and increased continuity of carer is anticipated to improve identification.

NHS Dumfries and Galloway established their dedicated Women Individually Nurtured Grow Strength (WINGS) team in 2019. WINGS team members are community midwives who have a special role with women and their partners who may require additional support during their pregnancy and when they have their baby. They have in-depth knowledge and skills and can refer to appropriate supports when additional needs are identified. They offer additional home visits and extra time to give the individualised level of care that women may need. They also make connections with other services that are already supporting individuals, other hospital staff when necessary, and can refer women to support agencies if required.

NHS Tayside has created a multi professional, multi service working group called Addressing Inequalities in Maternity Services (AIMS), whose aim is supporting the maternity service to reduce the impact of inequality – whatever that inequality is. The voices of women are invited in the form of attending sessions, being recorded, representatives speaking for them and written feedback. Currently under development are five deliverables, including standards, guidelines, a service booklet, additional appointments for midwives and women to identify additional needs, and a training package for maternity staff.

Progress Rating

All three recommendations for delivery of maternity care for women with additional complexities have been completed by Boards. Boards have undertaken work to better understand and meet the needs of their populations.

Recommendation 34

Systematic needs assessment focused and development of specific, targeted services for women with vulnerabilities, with team care constructed around women’s needs.

Rated: Blue

Delivery: Local Delivery

Recommendation 35

Staff training to support identification and support of vulnerable women as part of routine care, women with the most complex vulnerabilities access a specialist team. Midwives in these roles should have a reduced caseload and will act as the co-ordinator of team care for the woman and baby.

Rated: Blue

Delivery: Local Delivery

Recommendation 36

GPs and health visitors must be involved as part of the team in pre and postnatal care, and GP practices should identify a named link GP for vulnerable childbearing women and their babies.

Rated: Blue

Delivery: Local Delivery

Perinatal Mental Health

The Best Start made four recommendations (37 – 40) relating to perinatal mental health services and care, identifying areas for actions at a local and national level.

Some of the key actions relating to these recommendations are:

• Boards across Scotland have progressed in their implementation of specialist perinatal mental health, infant mental health and maternity & neonatal psychological interventions services.
• all 11 Health Boards who have a neonatal unit report that neonatal staff are able to refer parents to local psychological services, and parents are offered this throughout their neonatal journey, including at discharge. Maternity and Neonatal Psychological Interventions (MNPI) teams exist in most Boards. One Board, which does not have an MNPI team due to size, instead employs a perinatal mental health midwife and a clinical psychologist. Psychosocial support is one of the principles of the Bliss Baby Charter, which all Boards in Scotland are registered for. More information about the Bliss Baby Charter is available in the chapter on implications for neonatal care.
• all 14 Health Boards report that staff in their maternity and neonatal units have access to an up-to-date list of third sector support organisations operating in their area and are able to signpost families to this support.
• all Boards also report having established appropriate referral pathways, so parents can be referred to third sector support services.
• there are a variety of resources available to staff and families provided through the Perinatal Mental Health Network Scotland, including the Scottish Perinatal Mental Health Care Pathways.
• in line with the Perinatal and Infant Mental Health Curricular Framework, NES provide access to a variety of training modules and plans to support staff development in perinatal mental health.
• mental health in the perinatal period is included in the Mental Health and Wellbeing Strategy, most notably through the articulation of the life cycle approach. It is also included within the Delivery Plan in the action to continue to invest in and embed perinatal and infant mental health services at all levels of need so that women and families across all areas of Scotland have access to these services.

NHS Grampian’s Birth in Grampian website signposts to additional support and resources and is systematically reviewed to ensure it is up to date. Social media is also regularly used to raise awareness of the support available. All staff members are familiar with the options available and can provide hard copies of leaflets on the services. NHS Grampian also include third sector support organisations in their service delivery review group, the Grampian Perinatal and Infant Mental Health Collaborative and their Maternity Voices Partnership, helping to embed their work into maternity and neonatal services.

NHS Tayside opened their Maternity and Neonatal Psychology (MNP) service in 2022. The service is based in Ninewells Hospital and is a psychology-led service which is integrated within Ninewells Neonatal Unit. Prior to implementation, there was no established specialist psychology service for neonatal families, with parents likely to have accessed general adult mental health services in the community. MNP provides psychological support for mothers and fathers/partners whose babies are within NICU and up to one year of age post-discharge. MNP also supports the NICU team in providing high quality psychologically informed care. MNP staff are specialists trained in working with parents within the perinatal period and neonatal environments. Psychological support is provided within a tiered or stepped model of neonatal psychological care recognising that parents present with differing levels of support needs during a neonatal experience. If parents present with severe and complex mental health conditions, they may be directed to their local Community Mental Health Team or the Perinatal Mental Health Team for multi-disciplinary and psychiatric support to best meet their level of need. MNP has close interfaces with local Adult Psychological Therapies, Perinatal and Infant Mental Health Services and Child and Adolescent Mental Health Services (CAMHS) to support referral pathways. The service has been positively received by parents and NICU staff, who have given positive feedback on the helpfulness of being able to seek psychological advice in supporting parents particularly surrounding difficult conversations or diagnoses.

Progress Rating

The four Best Start recommendations relating to perinatal mental health services and care have been completed by the Boards and national bodies responsible for implementation.

Recommendation 37

Review of access to perinatal mental health services and adequate provision of staff training.

Rated: Blue

Delivery: National and Local Delivery

Recommendation 38

Perinatal Mental Health is a key focus in the forthcoming Mental Health Strategy.

Rated: Blue

Delivery: National Delivery

Recommendation 39

All neonatal staff can refer parents of babies in neonatal care to local psychological services.

Rated: Blue

Delivery: Local Delivery

Recommendation 40

All staff in maternity and neonatal units should be aware of, and signpost, to third sector support organisations.

Rated: Blue

Delivery: Local Delivery

Bereavement Care

The final two recommendations within the New Model of Care section of the ‘Best Start,’ Recommendations 41 and 42, concern the care and support given when a stillbirth, neonatal death or maternal death occurs. Though examples of good practice existed, it was recognised that there needs to be high-quality services which support families available regardless of where in Scotland they live.

These recommendations are being met through the National Bereavement Care Pathway (NBCP) Scotland Project, and supplementary work by the Paediatric End of Life Care Network (PeLICAN). Creation of national guidance for neonatal palliative / end of life care has been taken forward through the PeLICAN. PeLICAN have published guidance and a checklist for the NHS on their website to support the decision-making, transfer and end-of-life care of a child outwith the critical care unit or ward area. They have also published a Professional Information and Contacts Resource. The NBCP is funded by the Scottish Government and delivered in partnership with the pregnancy and baby loss charity, Sands. The NBCP provides dedicated, evidence-based care pathways designed for all healthcare professionals and staff who are involved in the care of women, partners and families at all stages of pregnancy and baby loss. There are five pathways: miscarriage, ectopic and molar pregnancy; termination of pregnancy for fetal anomaly; stillbirth; neonatal death; and sudden unexpected death in infancy.

Health Boards have been tasked with implementing all five pathways by the end of March 2025. Progress to date includes the following.

• All 14 Boards are now officially signed up to the NBCP, have appointed a NBCP lead and are at different stages of implementation.
• Health Boards report being at a range of stages of implementation, from being almost complete to still managing challenges in making the required changes. Boards have reported that one of the key actions which has had a positive impact on progress is the appointment of dedicated staff or staff time to lead implementation of the pathways. Examples given include the appointment of project managers and bereavement champions to help embed the pathways, as well as senior midwives taking on leadership of implementation as part of their role. Conversely, reported challenges include competing clinical pressures and delays in appointing staff to lead on the work.

A huge amount of work has been carried out in all Health Boards to improve the bereavement care provided. Some examples include:

• NHS Grampian was one of the Early Adopter sites for the NBCP and is on track to fully implement by the end of March 2025. NHS Grampian has longstanding partnerships with Sands. They have a dedicated ward for women and families to be cared in following loss of a pregnancy or death of a baby. Dedicated support is available from midwives, nurses and sonographers trained in bereavement care, as well as obstetricians with a role in bereavement care as part of their responsibilities. They are currently working towards a vision of providing high-quality care and support when a loss occurs outside of the dedicated ward, for example when a miscarriage occurs in the Accident and Emergency Department by introducing Bereavement Champions, who will have oversight for the pathways in their area of work, be a key contact for other staff, and signpost women and families to relevant support.
• NHS Lothian reported experiencing some challenges with implementing the pathways of the NBCP. Their primary challenge has been staff capacity due to competing clinical commitments. Other challenges have been the number and large size of the hospitals in NHS Lothian, and level of acuity as a regional centre. To address the challenges of introducing new pathways across a large board, NHS Lothian has created a Bereavement Champion role. Bereavement Champions are allocated one day per month of non-clinical time within their existing substantive posts as a short-term measure to assist with implementing changes and promoting progress.
• In NHS Lanarkshire, to expand the bereavement area more dedicated rooms for women who have suffered a loss have been identified and transformed in collaboration with Sands, the bereavement team, funeral directors, staff and the Lanarkshire community. Access points have also been created so families can access the bereavement area without passing by antenatal and labour wards, which can be upsetting for families who have recently experienced a loss.

Progress Rating

The timeframe for implementation of the NBCP was extended beyond mid-2024 to March 2025 to allow Boards time to introduce all five pathways. All 14 Boards are now officially signed up to the NBCP, have appointed a NBCP lead and are at different stages of implementation. The Scottish Government will continue to monitor progress of Boards towards full delivery of the NBCP.

Recommendation 41

Appropriate bereavement support, staff members trained in bereavement care, appropriate information about bereavement services locally, both in hospital and third sector services, and also information on follow-up care.

Rated: Green

Delivery: Local Delivery

Recommendation 42

Inpatient and community services should integrate end-of-life care pathways to support families in their choice if they would like to spend time with their baby at home or in a hospice.

Rated: Blue

Delivery: National Delivery