An introduction to maternity services in the NHS
Lack of knowledge about NHS structures and issues, as well as unfamiliarity with terminology, can be barriers to effective participation. This section sets out some basic structures, definitions and pathways of maternity care for England.
Maternity services cover care for women from when they become pregnant and access care to sign off by the midwife (usually around 10 days after the birth but can be up to 6 weeks postnatally). The components of maternity services are typically divided into the three stages of pregnancy, namely antenatal, intrapartum (birth) and post natal care. In addition, neonatal care can be seen as an extension of maternity care as the baby has not yet been discharged home.
It is essential that there is clear communication and the sharing of information between healthcare professionals to ensure that care provided at different stages is woman focused, family-centred and safe.
Antenatal care generally commences between 9 - 12 weeks into pregnancy and the purpose is to support women and their partners during pregnancy and identify potential problems with mother and baby early through detailed history risk taking and risk assessment. Good antenatal care is essential in providing choice for women. It is important that women and their partners are given the information to enable them to make an informed choice over all aspects of their pregnancy.
Women can be referred to antenatal services by their GP or alternatively they can access antenatal care directly by contacting their midwife when they think they are pregnant. Antenatal screening and scanning is hospital based and it is crucial that it occurs at defined stages of pregnancy. For women who are assessed to be "low risk", care is typically provided by midwives working from community health facilities, GP surgeries and increasingly from Children's Centres. At Children's Centres midwives work in partnership with other agencies in areas of social deprivation to try and influence improved health outcomes for mothers, babies and families. If a woman has complications then she will typically be placed under the care of a named hospital consultant. Her antenatal care will be provided within an acute trust setting whilst ongoing links with the community midwifery team will usually be maintained. Some hospitals have established Early Pregnancy Units (EPUs) which are midwife/nurse/consultant led clinics that provide assessment and care for women who have problems in early pregnancy.
Antenatal classes/parentcraft classes
Antenatal / parentcraft classes should be offered to women and their partners about eight to ten weeks before the baby is due. They are in addition to antenatal care and cover topics such as health in pregnancy, what happens during labour and birth and caring for your baby. Classes may be run by hospital midwives, community midwives, GPs, health centres or the National Childbirth Trust (NCT). Primary Care Trusts (PCTs) currently commission the maternity service as a package and generally do not commission antenatal classes specifically, although changes to the payment tariffs will include costing classes separately.
There has been recent media attention regarding cuts in classes and an increase in women having to pay for private classes. There is a lack of statutory regulation covering the provision of antenatal classes and there are fears that unqualified teachers may be providing advice. It is also paradoxical that it is typically women with the greatest social and emotional need who will not access antenatal classes and this has implications for the emotional and physical wellbeing of mother, child and the family and hence the Children's Centre type models which are being developed.
Intrapartum care covers the onset of labour through to immediate care after birth (first, second and third stages of labour). Depending on the needs of a woman and the services available in her local area, a woman will give birth in one of the following settings.
Obstetric unit/Team based care
A unit in which care is provided by a team, with obstetricians taking primary professional responsibility for women at high risk of complications during labour and birth. Midwives offer care to all women in these units, whether or not they are considered at high or low risk, and take primary responsibility for women with straightforward pregnancies during labour and birth. Diagnostic and treatment medical services, including obstetric, neonatal and anaesthetic care are available on site.
Alongside midwifery unit
A unit offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care. During labour and birth the full range of diagnostic and treatment medical services (including obstetric, neonatal and anaesthetic care) are available in the same building, or in a separate building on the same site should they be needed. Transfer will normally be by trolley, bed or wheelchair.
Freestanding midwifery unit
A unit offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care. General Practitioners may also be involved in care. During labour and birth, diagnostic and treatment services (including obstetric, neonatal and anaesthetic care) are not immediately available but are located on a separate site should they be needed. Transfer will normally involve car or ambulance.
If a woman is low risk in theory she should be offered a planned home birth. A women who chooses to have a home birth will be looked after by community midwives attached to a local maternity unit. Once in labour, the midwife stays with the woman until the baby is born, and will visit regularly for between 10 and 28 days after the baby has been born.
High risk births in low risk models of care
Occasionally women who are not considered low risk choose low risk models of care that are not suited to their risk factors. For example women with a breech presentation, twins or previous history of caesarean section choosing a home birth. In these circumstances midwives have a legal obligation to continue to provide intrapartum care and advice to the woman of the appropriate type of care required and to seek support from the hospital staff, supervisor of midwives and ambulance services as needed. The rate of Born Before Arrival of health professional (BBA) is an important indicator of deprivation or quality of antenatal service; these are often women without confident or convenient access to their health professional or are due to unexpected prematurity. A small number are a result of a previous poor care experience.
Most women leave hospital within 1-2 days of the birth of their baby. Community midwives visit at home generally until the tenth day postnatally (depending on the women's needs). They formally hand over care to health visitors at 10-28 days depending on local arrangements. Women who have had complications may be transferred to a postnatal ward. Care provided should respond to the physical, psychological, emotional and social needs of women and their family in a structured and systematic way
Neonatal care is provided for newborn babies who are premature and/or experiencing complications. Neonatal care networks have been established since 2004/05 and are the recommended vehicle for providing a more structured and integrated approach to care. Agreed referral pathways should exist across a network to ensure effective arrangements for managing the prompt transfer and treatment of women and babies experiencing problems. They should be designed to ensure that mothers and babies receive care within their local network, in a unit that is at the level appropriate for their needs, as near to home as possible.
Within a neonatal network, different neonatal units will provide different levels of care. Level 1 units provide special care only. Level 2 units provide high dependency and limited intensive care. Level 3 units provide the full range of intensive care and some will also provide neonatal surgery and other specialized services, for example, cardiac. Issues of capacity, transfers and staffing shortages within the neonatal system can result in mothers and their babies transferred long distances in order to access the right level of care.
Networks link groups of health professionals and organisations (from primary, secondary and tertiary care, and social services) to ensure equitable and cost-effective provision of high quality, clinically effective care. Managed networks in maternity are relatively less established than neonatal networks but include arrangements for managing the prompt transfer and treatment of women and babies experiencing problems or complications, by ensuring there are agreed referral pathways across the network.