Overview & Scrutiny Committee Maternity Services Review

1. Overview & Scrutiny Committee Maternity Services Review Margaret Cronin Head of Midwifery & Gynaecology Services WHHT Maternity Services - Overview & Scrutiny Committee

2. Overview of services • Deliver 5600-5700 women/annum • Provide a full range of antenatal, labour and postnatal care, both midwifery led and obstetric led • @69% Mainly from surrounding areas of • Watford • Hemel Hempstead • St Albans • @ 31% Border areas – provide targeted services for @ 2500 women • Barnet & Enfield - Luton & Dunstable • East & North Herts - Stoke

3. Antenatal Continuity of Care(r) & Choice • Three community teams – Hertfordshire • Watford, Hemel Hempstead & St Albans • 75 GP practice locations – continuity of care model • 1 Children’s Centre running South Oxhey • 1 Children’s Centre to start Hillside • Week day & Weekend clinics in hospital bases • One hospital based team – out of area women choosing to deliver their babies with us • Developments in 2008-date • Early access: Speed booking • Parent education • VBAC clinics

4. Information & Choice • Mandatory multidisciplinary staff training • Evidence based practice – NICE, Confidential Enquiries etc • Risk Assessments (RA) • At booking & reviews throughout • Options • Screening • Health Promotion advice • Explored based on RA’s: plans of care made & revised • Options for place of birth • Homebirth • Alexander Birth Centre (Alongside Birth Centre) • Delivery Suite (Obstetric-Led Unit)

5. Labour Continuity of Care & Choice • Care provided for @5650 women • Homebirth – West Hertfordshire women only 3.89% Community midwifery teams • Alexander Birth Centre 22.11% ABC team Low risk women booked with WHHT • Delivery Suite 74% Delivery Suite team Women requesting epidural analgesia or where intervention required, booked with WHHT • Delivery Statistics 2008-09 Vaginal Delivery 60.5% Caesarean Section 25.9% Instrumental Delivery 13.6% Perinatal Mortality rates: 0.9/1000 live births (EoE: 1.7 UK: 2.0)

6. Postnatal Continuity of Care & Choice • Hospital based services (Postnatal ward team) • Midwives, Nursery Nurses, Maternity Care Assistants: Paediatricians & Obstetricians • Average Length of Stay (LoS) • ND without complications <12 hours (ABC) • ND with complication or instrumental delivery @ 1 day • Instrumental with complications @ upto 2-3 days • Caesarean section @ 3 days • Community Midwifery teams • Provide care West Hertfordshire women - @ 3.4 visits/ woman • Nb @ 2500 additional imports – ie women gave birth in another maternity unit, but live in WHHT community area • Neonatal Screening

7. Pathways:69% of women booked at WHHT • Access & referral • See GP/mw in surgery, +/- discuss options on which maternity service to refer to referral to maternity services made (WHHT) • Booking • With midwife – location GP practice, hospital base, home (few) • Risk Assessment • Health Promotional advice • Screening options • Provisional plan of care

8. Pathways cont… • Follow up appointments • With midwife/GP – low risk women – RA each visit & revision of plan of care • Screening – eg scans, blood tests, MRSA • In conjunction with obstetric or other teams if high risks develop • Parent education • Consistent evidenced based information: Offered to all women booked with WHHT • Labour • In appropriate care setting and in accordance with women’s informed choice • Postnatal care

9. Pathways:31% of women using WHHT services • Applies to women using some aspect of antenatal or postnatal care but booked at an alternative maternity unit for delivery of their babies. Affects community aspects of WHHT maternity service provision • Variations in services offered and lines of communications between maternity services. • Potential risks mostly mitigated against by having well established community midwives in local communities, familiar with nuances of services.

10. Cross Border issues • Changing and varying policies in maternity services: • Combined screening • Access to parent education • Hepatitis immunisation • Use of maternity service specific documentation & reconciliation of records • Referral processes not always well articulated • Eg access to mental health services, HV teams etc • Relies on midwives local knowledge

11. Cross Border issues cont… • Access to results • Some midwives have to phone one or a number of contacts, others have net access at GP practices. Others have the results filed in hand held record • Access for women to parent education • An issue for women living in Tring area and choosing to deliver at Stoke • Notification in service changes • Networks well established in EoE area and with Barnet & Chase • Networks not so well established with other regions

12. Health promotion • Infant feeding • Breast feeding coordinator post – N Nurses Hosp & Com Report rates Q2: Intended Actual Breast feeding alone 83.91% 71.02% Breast & Mix feeding 85.75% 84.23% Artificial feeding alone 14.25% 15.77% • Smoking cessation • Screening at booking & referral to cessation programme Smoking at: Booking 16.% Delivery 11.% Discharge 7% • Obesity • Revision of policy in accordance with NICE - Improved RA Report rates Q2:BMI 30-34.9 = 9.42% BMI 35+ = 5.45%

13. Service Developments • Maternity Matters Action Plan • Midwifery staffing • Services specification – reconfigure community midwifery services – project plan start in January 2010 • Vulnerable adults and mental health pathways • Infant feeding • Combined screening