Hampshire Health Review Committee Item 4

Maternity Services Consultation -

Proposals for the reconfiguration of maternity services at Queen Alexander Hospital, Portsmouth

Working Group:

Cllr Bayford

Cllr Mrs Dickens - Chairman

Cllr Ellis,

Cllr Mrs McNair Scott

Penny Velander - Health Review Officer

1. Introduction and overview

1.1 Preliminary notice has been given by Queen Alexandra Hospital that there is to be a major change to the way maternity services are delivered in the area. This change forms part of the overall HealthFit proposals which cover all of the Strategic Health Authority area ie Hampshire, Portsmouth, Southampton and the Isle of Wight

1.2 HealthFit is a strategic document that offers a blueprint for the development of health services in Hampshire and the Isle of Wight. It describes the key strategic issues facing the local NHS and those who work with it, offers a vision for the improvement of specific services and explains some of the work that must be done now to underpin changes. It has been developed, not just by the Strategic Health Authority (SHA) but also by primary care, acute and specialist trusts in the area and by doctors, nurses and other clinical experts. The vision, principles and descriptions of care will be used to inform the future planning of all clinical services. HealthFit places emphasis on the importance of innovation, financial planning and the development of locally led solutions.

1.3 More detailed planning has taken place locally within the PCT's concerned. Hampshire Health Review Committee is waiting for further information on these plans and will be scrutinising both the reconfiguration and the services that are envisioned.

2. National drivers

2.1 Three recent documents have influenced current perspectives for good maternity services. All advocate the principal that pregnancy is not an illness and that services should be designed around women's needs

2.2 Report to the Department of Health Children's Taskforce from the Maternity and Neonatal Workforce Group - January 2003. This group was established because of a recognition that a national perspective was needed to deal with the growing number of developments at a local level. Recommendations are suggested to influence thinking at both a national and local level

2.3 The Emerging findings on the National Service Framework (NSF) for Children, Young People and Maternity Services - April 2003 sets out a 10 year programme which aims to `ensure fair, high quality and integrated health social care services from pregnancy, where every child's life begins, right through to the transition to adulthood'. Maternity services - from pre-conception care to post-conception period- are included with an emphasis on `the best possible start'. The emerging findings also advocate setting standards of care to reduce health inequalities.

2.4 The National Institute for Clinical Excellence (NICE) Guidelines on Anti-natal Care - October 2003 provides practical advice for clinical antenatal care for all healthy women and baseline care for all pregnancies

2.5 The final version of the National Framework for Children, Young People and Maternity Services is expected July 2004

3. Healthfit reconfiguration

3.1 Healthfit plans for Portsmouth and South East Hampshire maternity services are:

· In 2003/04, Portsmouth and South East Hampshire will publish and consult on a district-wide maternity strategy that will define the model of service that reflects contemporary best practice. It will also review the number of services to be provided including midwife-led maternity units - and their location.

· In 2004 Portsmouth Hospitals Trust and the Isle of Wight Trust will agree transfer protocols for babies needing neonatal intensive care.

· In 2007/08, Portsmouth's obstetric unit will move from St Mary's Hospital in Portsmouth to the redeveloped Queen Alexandra Hospital in Cosham.

3.2 In addition Health plans for the Isle of Wight will provide a `knock-on' effect as:

· Women with the most high-risk pregnancies will plan to give birth in the nearest mainland units with available capacity.

· It has been estimated that ten babies a year are born on the Isle of Wight who may need neonatal intensive care, which would be more appropriately delivered from a specialist neonatal intensive care unit on the mainland. An agreement for the clinical care of these babies and their mothers will be made with Portsmouth Hospitals Trust.

3.3 It is also worth noting that many intensive care neonates from the Isle of Wight are currently transferred to Southampton's Princess Anne Hospital. This Unit, although large, occasionally experiences overflow problems which leads to the need to transfer babies to other hospitals.

4. Healthfit services

4.1 Maternity services focus on providing optimal care for every woman and baby as well as offering women support and information, so they can make their own decisions and choices about care during pregnancy, in childbirth and in the care of the newborn infant. There are a number of challenges for maternity services across Hampshire and the Isle of Wight. These include:

· A shortfall in trained doctors and neonatal nurses, which will be accentuated by the need to comply with the Working Time Directive

· _the requirement that modern maternity services be based primarily in community settings. This necessitates a comprehensive review of where care is given and which health care workers give it

· _the need to give women more choice about how and where they give birth, which must be balanced with what is clinically appropriate

4.2 The HealthFit vision is that all services should:

· Be centered around the wishes and needs of women, their families and communities, and offer women real choices about their care

· Be accessible, flexible and, wherever possible, local

· Be clinically appropriate and safe for both mothers and newborns, according to the best available evidence

· Be provided in centers equipped appropriately to cope with the anticipated level of complexity and risks

· Contribute to public health outcomes and reduce health inequalities

· Enable seamless care across the primary, secondary and tertiary sectors

· Use and develop professional skills efficiently and effectively

· _be cost-effective and sustainable

· Work in partnership with other statutory and voluntary agencies in order to improve outcomes and increase patients' satisfaction

4.3 This vision fits closely to the principals set out in the key documents in item 2 and the identified care pathways follow the Nice guidelines. However until the district wide maternity strategy is launched there is a lack of detail to consider and scrutinise. An example of this is details to support teenage parents.

5 Teenage Pregnancy

5.1 In 1999 the government launched its Teenage Pregnancy Strategy aimed at halving the under 18-conception rate and supporting teenage parents to reduce their long-term risk of social exclusion. Each council with Social Services responsibility has to have a teenage partnership board and is responsible for developing the local 10-year strategy. Between 1998-2001 there was a 10% reduction in the under 18-conception rate however the UK continues to have the highest rate of teenage births in Western Europe.

5.2 National targets are set to:

· Continue the reduction in under 18 conception

· Reduce infant mortality by 10%

· Increase breastfeeding

· Reduce smoking in pregnancy

· Increase teenage mothers in education, employment and training to 60% by 2010 (currently 30%)

5.3 National statistics:

· In England in 2001 there were 38,439 conceptions to women under 18, a conception rate of 42.3 per 1,000. Of these 7,396 were to girls under 16, a rate of 7.9 per 1,000; around 46% of these pregnancies led to termination.

· Risk of teenage pregnancy is ten times higher for a girl in lower social classes compared to professional groups

· Two-thirds of teenage mothers smoke before pregnancy and 40% continue during the pregnancy

· Babies born to mothers under 18 are 25% more likely to be born at a low birth weight

· The infant mortality rate for babies of teenage mothers is 60% higher than for other mothers

· Fewer than half of mothers under 20 initiate breast-feeding compared to over three-quarters of mothers over 30.

· Teenagers are three times more likely than older mothers to experience postnatal depression

· Babies of teenage mothers have been found to face a higher risk of prematurity; hospitalisation for accidental injuries, diarrhoea and vomiting; developmental delays and poor levels of nutrition

· Children of teenage parents are more likely to be at risk of a variety of behavioural problems including truancy and running away from home

· Teenage pregnancy is a major cause and consequence of social exclusion

5.4 Regional statistics:

· In the South East there were 5,022 conceptions to women under 18, a conception rate of 34.8 per 1,000. 49% of these led to termination and there were 2,559 births

5.5 Hampshire statistics:

· Since 1998, in Hampshire, the provisional Under 18 conception rate has dropped by 19.5% to 29.6 conceptions per 1000 young women. This compares well to the national rate of 42.6

· Havant and Gosport have the highest incidence of teenage pregnancy in Hampshire

5.6 Despite the relevance of the 1999 Teenage Strategy to maternity provision no mention of it is made throughout Healthfit maternity plans. The Hampshire Teenage Pregnancy team working in South-east Hampshire identified the following issues

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5.7 There is a very low rate for teenagers accessing antenatal care. This is due to a number of reasons from late identification of pregnancy, fear of stigmatisation, lack of confidence and feeling uncomfortable with the language used. Teenagers who become pregnant need support and care that is targeted at there specific needs. To overcome these problems there needs to be a designated midwife for teenage parents in Havant and another in Gosport

5.8 Access to maternity services is often a problem for teenage parents. Planners should ensure that public transport routes to maternity hospitals are mindful of their circumstances. For example buses with low access floors. In addition schemes should be explored for bus fares to be refunded or bus passes issued to teenage parents.

5.9 All information relating to pregnancy, care and services needs to be teenage friendly. Leaflets, especially, need to examine the language used and adopt appropriate communication levels. Thought needs to be given to teenagers with special learning needs and likely reduced reading skills

6. Conclusion

6.1 The Strategic Health Authority has widely promoted the HealthFit document laying out their vision and plans for future maternity services across Hampshire.

6.2 Further in-depth information is awaited which will give greater detail on the changes to be made and services to be provided.