Maternity, Neonatal and
Paediatric Service Strategic
Framework
November 2016
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16.209.2 Appendix 3
CONTENTS
Page No.
1. Introduction
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2. Framing the Strategy
National and local strategic drivers
Fixed points for the service areas
Outcomes we seek to achieve
Challenges
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7
3. Diagnose the Current Position
Assessment of Population Health needs
Summary of Key Messages
Population and service user experience and feedback
Staff feedback
Relevant Evidence Base, Quality Standards & Outcome
Indicators
Current performance against standards and indicators
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4. High Level of Mapping of services, estates and resources
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5. Workforce
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6. Initial identification of principles for the future Strategy
 Principles for future strategic direction
 Identification of service components and levels of care
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36
7. Engagement with staff, service users and partners to
understand and respond to views and needs
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8. Next Steps
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Appendix 1: List of Evidence, Standards and Reviews
43
Appendix 2: Glossary
44
Appendix 3: Acronyms
46
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16.209.2 Appendix 3
1. INTRODUCTION
Betsi Cadwaladr University Health Board is developing a strategy for health, wellbeing and healthcare in North Wales called Living Healthier, Staying Well. This
strategy will set out the strategic vision for the Board and will reshape how we
support good health and provide healthcare for the medium to longer term.
The approach will be based on three overlapping major programmes within the
overall portfolio:
 Improving health and reducing inequalities
 Care closer to home
 Acute hospital care
Work has now begun to develop the strategy in each of these three programmes as
well as a Children’s Strategy. This work will continue into the new year when further
engagement will take place regarding details of service development and change.
Under the Special Measures Improvement Framework, the Health Board is required
to produce a Framework for Maternity, Neonatal and Paediatric Services. This paper
is a positioning paper which addresses this requirement and sets out a summery of
the following:
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What we know about maternity, neonatal and paediatric services
How these fit within the broader service networks supporting women and their
families
The outcomes we want to achieve for our population
The principles we will adopt in developing the detail of future service models.
The scope of the paper is confined to maternity and neonatal services and that
element of paediatric services required to support neonatal care. There is a direct
operational link between obstetrics and gynaecology but for the purpose of this
Framework, we will focus on the obstetric element. Gynaecology will form a critical
part of the overall Women’s Services Strategy, which will be informed by this
Framework.
The Women’s Services Strategy will be linked into the Acute Hospital Care
programme; however it is important to note there will be clear links with the Care
Closer to Home programme, reflecting the vital importance of strong community
midwifery support.
This paper is not the strategy itself. We will develop this over the coming months,
working with partner organisations and stakeholders including women and their
families to co-design future models of care and support.
The report is intended to demonstrate progress on work to support the final strategy
and set out the potential parameters for the detailed work which will follow. The
paper builds on work that we have been doing to date.
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Clinical and operational leaders of women’s services are committed to working
together on a plan that will ensure the future sustainability of safe, high quality
women’s services, including Consultant Led Obstetric Services at the three District
General Hospitals. At a recent workshop of this group there was agreement that to
achieve this there would need to be changes in how we work, and agreement on teh
following key messages:
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too many babies are born in the traditional “hospital settings’
we need to enhance our community services
we need to improve the support given to all women and their families
we need to apply the principles of prudent health care.
We need to get maternity care right and strengthen the contribution to give all
children the best start in life through protecting and promoting the health and
wellbeing of the mother and family. Unfortunately, not every child currently
experiences this as there are significant inequalities in maternal and infant health
outcomes. We must take the opportunity to change this for the better.
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2. FRAMING THE STRATEGY
2.1 Scope of the Framework
There is no single overarching group which has developed this Framework, the work
has been considered and taken forward by a number of existing groups.
The key groups supporting the framework are:
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Women’s Divisional Board
North Wales Maternity Strategy Implementation Group
Children’s Transformation Group
SuRNICC Implementation Group
These groups all have strong clinical support from a range of health care
professionals and partners including medical, midwifery, nursing, therapy staff,
workforce, trade union, and service user, Social Services, Local Authority and Third
Sector.
This Framework and subsequent maternity element of the overall Women’s Services
Strategy will be designed to address all care from conception, throughout pregnancy
and the newborn with a clear and strong focus on well being, prevention and early
intervention.
The term maternity care will include any NHS service providing maternity care to
women and their babies including midwives, obstetricians, paediatricians,
neonatologists, neonatal outreach, Allied Health Professionals, perinatal mental
health, safeguarding, genetic services etc.
Effective collaboration and
communication between all these disciplines and services is essential for person
centred, safe and effective maternity and care of the newborn. Whilst this
Framework will focus on maternity care it will also recognise the critical interface with
Gynaecological, Anaesthetic and Radiology services as well as other disciplines
providing services for women, babies and their families.
2.2 Areas of Overlap and Key Interdependencies
Maternity services are not provided in isolation. They require other services around
them to offer safe, effective care. It is crucial that these clinical interdependencies
are recognised at the outset.
The key interdependencies with other services and strategies have been identified
for this work. They are recognised in a number of reports most recently in the Royal
College of Obstetricians and Gynaecologists report 2015 – ‘Options appraisal of
Maternity Services at Betsi Cadwaladr University Health Board’. They are also
outlined in the 2013 Royal College of Paediatrics and Child Health ‘Invited Review of
the Options for Provision of Neonatal Care in North Wales’ (the RCPCH review) and
summarised in the SuRNICC Outline Business Case
http://www.wales.nhs.uk/sitesplus/861/page/84322
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16.209.2 Appendix 3
In relation to Maternity services the key critical interdependencies are:
 Gynaecology - Majority of Obstetricians also provide gynaecology care
 Imaging and Radiology - Sonography
 24 hour Acute Paediatrics- provide of a minimum of a Special Care Unit to
support a Consultant Led Obstetric Unit
 Obstetric Anaesthetics - Epidural pain relief and emergency intervention
 Theatres
 Adult Critical care
 Access to the full range of support services – Radiology, Pathology, Radiology,
Pharmacy, Therapies
In relation to neonatal care, the RCPCH review specifically identified the following
services as essential on a site that provides neonatal care:
 Co-location with a Consultant Led Obstetric unit
 24 hour Acute Paediatrics - required for all levels of neonatal care
 Access to the full range of support services e.g. Radiology, Pathology,
Radiology, Pharmacy, Therapies
2.3 National and Local Strategic Drivers
There are a wide range of national and local strategic drivers which will impact upon
the way services are designed and delivered. For the purpose of this framework the
focus will be on the following:2.3.1 National Drivers
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A Strategic Vision for Maternity Services 2011 (undergoing a refresh to
incorporate Prudent Maternity Care)
All Wales Neonatal Standards 2012 2nd Edition (Based on British Association of
Perinatal Medicine – BAPM, 3rd Edition pending)
National Neonatal Audit Programme 2016
Maternity Network for Wales (Including National Stillbirth and Quality & Safety)
First 1000 days collaborative
Reducing the Number of Adverse Childhood Experiences (ACEs)
2.3.2 Local Drivers
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North Wales Population Health Needs Profile
North Wales Maternity Strategy Delivery Plan 2016
Royal College of Obstetricians and Gynaecologists Recommendations and
Reports
Special Measures Improvement Framework Requirements of o Continued Improvement in the culture and clinical leadership within
maternity services
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16.209.2 Appendix 3

o Continuing improvement against the national maternity services
performance dashboard
o Satisfying national and statutory requirements for mandatory training within
maternity services
o Clarity about the future strategy and service plans to support the SuRNICC
Implementation of the Neonatal service model for North Wales including the full
establishment of the SuRNICC at Glan Clwyd Hospital (YGC).
2.4 Fixed points and ‘Givens’
2.4.1 The SuRNICC development is now underway and will be located at YGC. It will
be supported by two Special Care Units (SCU) at Wrexham Maelor Hospital (WMH)
and Ysbyty Gwynedd (YG). The North Wales Neonatal Transport Team will continue
to be located at YGC. The implementation of the network of neonatal units will result
in both the redistribution of clinical care within North Wales and a reduction in both
the number of babies treated outside North Wales and the length of time over which
they receive such treatment.
2.4.2 The Health Board is committed to providing Consultant - led Obstetric services
at the three District General Hospital sites. This requires a plan to be developed that
will ensure their future sustainability in providing safe, high quality care. The work to
develop that plan has commenced.
2.4.3 Midwifery - led Units (MLUs) will be co-located with the Consultant Led
Obstetric Units on each of the three District General Hospital sites
2.4.4 There will be a range of support services to support the three units including
radiology, pathology, pharmacy, therapies
2.4.5 Community Midwifery Services will be available locally in line with Care Closer
to Home, including providing support for women to give birth in Free Standing
Midwife Led Units (FMLU) and at home
2.4.6 There will be three Paediatric in-patient units to ensure each Obstetric Unit is
supported by a minimum of a Special Care Unit
2.4.7 Obstetric Anaesthetic services, adult critical care and pain services will be
available on the three sites
2.5 Outcomes we seek to Achieve
The ‘Vision for Maternity Strategy in Wales – 2011’ sets out clear outcomes for
Maternity Services, as does the Royal College of Paediatrics and Child Health
(RCPCH). Key outcomes have been identified as set out below. These will be
further developed as part of the emerging framework for delivery of women’s
services and the strategy work undertaken by the other programme groups;
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16.209.2 Appendix 3
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Healthy and well supported new familes
Effective engagement with service users
Healthy mothers and babies – fewer premature and low birth weight deliveries
Women have access to a range of safe high quality maternity services that
meet their needs
Evidence based services provided by a highly trained and educated workforce
able to deliver safe, high quality maternity and neonatal care
Every child has the best start in life
Improved child health, mental health and well being
Children are protected from harm and neglect
The most vulnerable children and families will be supported
Improved opportunities for better long term health and well being into adult
hood
Reduced Adverse Childhood Experiences (ACEs)
2.6 Challenges
We need to look at how we might do things differently so that we take every
opportunity to improve health gain and prevent illness or complications. Our focus
will be to do more to support health and wellbeing as opposed to providing a reactive
response to illness.
There are a number of constraints in delivering women’s and newborn healthcare
which have been identified, as follows;Workforce – Given the current workforce pressures including the age profile in
midwifery, there is a need to think differently about how services can be provided
and by whom. The number of places for training doctors (Obstetrics & Gynaecology,
Paediatrics, Neonatal, Anaesthetics, and Radiology) and the ability to fill these
places is challenging. In addition the current number of training places for midwives
and nurses (neonatal, paediatric and general) are not sufficient to meet our
requirements with our current model of service. Therefore we must review the way
we seek to provide these services.
Financial pressures - The economic challenge for all public services in delivering
efficiencies in the current financial environment is creating the need to constantly
evaluate the impact of current and new investments. There needs to be a consistent
application of the principles of Prudent Health care. We are facing the challenge of
the need to shift resources to focus on prevention and early intervention particularly
in relation to the first 1000 days from conception.
Providing more care in primary and community settings– Providing more care and
support in primary care and community settings and less in the more ‘traditional
hospital setting’ will bring direct benefits to those who access these services.
Additionally, it could allow specialist and complex care services to be strengthened
by releasing scarce skills and resources. Much of this is reflected in the principles of
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Prudent Maternity Care which looks at practicing normality and giving women the
choice to birth outside of an obstetric unit.
Changes in demographics and increasing complexity – The demography of women
currently needing obstetric and maternity services is becoming more complex due to
the increasing age of the mother, maternal obesity, the incidence of multiple
pregnancies and other co-morbidities. The greatest potential improvement in
maternal outcomes and longer term health gain could be achieved by tackling public
health measures e.g. social deprivation, smoking cessation, obesity etc.
Staff, Service user and public expectation (cultural change) – We want to see more
services being delivered in primary and community-based settings, which have
traditionally been hospital based. We do however recognise the need to provide the
evidence and information to the public that informs their choice and assures them
that this is safe.
Estate and Accommodation – Capital investment may be required to ensure that
secondary care and community facilities for staff and service users are fit for purpose
and enable us to achieve the improved outcomes for staff attraction and retention.
Information and Communication Technology – This is essential to help deliver high
quality services. Sharing information across sites will be crucial to ensure that we
can provide a safe network of services.
Changes / service reconfiguration of neighbouring providers – we are not yet clear
as to potential changes in service provision and their implications in the following
areas –
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Countess of Chester neonatal unit temporarily re-designated as a SCU
Future Fit with the non-financial preferred option of emergency care and
therefore Obstetric Services will be at Shrewsbury Hospital
Model of care provided at Bronglais Hospital, Mid Wales Health Care
Collaborative
Outcome of the Cheshire & Merseyside Maternity, Paediatric &Neonatal
Vanguard project
Our planning work going forward must address these challenges to ensure that
services are safe, offer high quality care and are sustainable.
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16.209.2 Appendix 3
3. DIAGNOSE THE CURRENT POSTION
3.1 Assessment of relevant population health needs
The North Wales Public Health Team has produced a ‘Population Health Profile of
North Wales, to support needs assessment for Social Services & Wellbeing Act and
wellbeing assessment for Future Generations Act’ May 2016’. The report considers
a range of population evidence including, deprivation & inequality, health & wellbeing assets, mortality and morbidity, mental health & well-being.
The report confirms that there are many challenges in North Wales relating to
maternal and child health. Deprivation and the lifestyles associated with socioeconomic deprivation have particular impact on maternal health and the positive
outcomes of pregnancy. Key messages from the report relating to maternal and
child health indicate that there are challenges in rates of stillbirth; preterm birth; low
birth weight (LBW); neonatal deaths; admissions to neonatal units; infant mortality
and teenage pregnancy, maternal health factors such as smoking and obesity. All of
these have been shown to be significantly higher in areas with high levels of
deprivation.
Child poverty remains high across Wales with 30.4% of children living in poverty.
There is evidence that childhood poverty leads to premature mortality and poor
health outcomes for adults. Reducing the numbers of children who experience
poverty should improve these adult health outcomes and increase healthy life
expectancy. The numbers of children living in poverty varies across North Wales
ranging from 23.6% in Gwynedd to 32.2% in Denbighshire.
High quality and high level antenatal and obstetric care become more important in
areas of greater deprivation where there is higher probability of poorer health and
potential for more adverse outcomes.
3.1.2 Infant Mortality – Infant mortality is a measure of the rate of deaths in children
aged less than one year. It gives a good indication of the overall health of children
and is strongly influenced by the health of mothers before, during and after
pregnancy. During the period 2005 – 14, the infant mortality rate for BCUHB was 4.5
per 1,000 live births compared to 4.1 per 1,000 in Wales. Again there is variation
across North Wales, with Anglesey the highest at 5.2.
3.1.3 Stillbirths – There are risk factors which can increase the risk of stillbirth, these
include smoking and drinking during pregnancy, as can being overweight or obese,
or having children later in life.
3.1.4 Low Birth Weight (LBW) for Singleton Births – In Wales there is a clear link with
LBW and socio-economic deprivation. The highest LBW rate is in the poorest areas
and it is almost twice the rate found in those areas with the lowest rates of LBW. In
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2014 the lowest LBW was 3.8% Conwy, with the highest in Wrexham and
Denbighshire at 6% compared with the BCUHB average of 5% (All Wales 5.1%)
3.1.5 Teenage Conceptions – Underlying factors which can increase the risk of
teenage pregnancy, include poverty; low educational attainment; poor attendance at
school; non-participation in post-16 learning and low aspiration.
A recent report by Public Health Wales (2016) highlighted the following:
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Infant mortality rate for babies born to teenage mothers is 60% higher than for
babies born to older mothers
Teenage mothers are more likely to smoke and less likely to breastfeed
Teenage mothers have three times the rate of post-natal depression of older
mothers and higher risk of poor mental health for three years after birth
Rates of teenage pregnancy are highest among deprived communities
3.1.6 Summary of Key Messages;
Smoking in pregnancy is associated with serious pregnancy-related health
problems. These include: complications during labour and an increased rate of
miscarriage, premature birth, stillbirth, LBW and sudden unexpected death in
infancy. Smoking during pregnancy also increase the risk of infant mortality by an
estimated 40%
Breast Feeding – Breastfed babies have; less chance of diarrhoea and vomiting
fewer chest and ear infections and having to go to hospital as a result, less
likelihood of becoming obese and therefore developing type 2 diabetes and other
obesity-related illnesses later in life.
Low Birth Weight – low birth weight has strong links to poorer health outcomes
and is associated with material deprivation later in life
ACEs - In Wales those who suffered four or more adverse experiences in childhood
are more than twice as likely to be diagnosed with chronic disease as adults who
did not suffer adversity
Children of teenage mothers are generally at increased risk of poverty (63%)
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3.2 Population and service user experience and feedback
3.2.1. Public Consultation – what people said
During 2015 the Health Board undertook a public consultation - ‘Temporary Changes
to Women’s and Maternity Services in North Wales – Have Your Say’. A range of
methods were used to gain views of the public, service users, staff and partners as
part of the consultation process. The outcome report and supporting evidence was
presented to the Health Board on 10th December 2015. It is important that we
demonstrate how we have listened to, and used the views shared with us during this
consultation to inform our service planning.
3.2.2 Key Themes Raised from Public Consultation Feedback
The feedback received across the consultation revealed a range of concerns about
the implications of change. Specifically, the most widely aired concerns tended to be
around whether transport networks and infrastructure in North Wales would be able
to support the safe transfer of mothers requiring emergency consultant-led treatment
as a result of complications in pregnancy or labour. Other feedback highlighted
concerns around workforce issues such as staffing and recruitment and the potential
impacts on other services. Key issues identified were
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Minimise risk to mothers and babies
Need more staff / better recruitment of qualified staff; make more temporary
staff permanent; fewer locums / temps
The need for local / quick access and the need for hospitals to be close to
home e.g. people can’t afford to travel far, hospitals are too far apart, other
hospital too far away
Impact on mother and baby travelling distances
3 sites needed to maintain a good geographic spread
Strong disagreement with the proposal for temporary change whilst others
agreed with the need for change
A risk to lives / safety e.g. due to sudden emergencies in ‘low risk’
pregnancies
In summary, comments about the pros and cons of the various options were based
on the following themes o Transport, travel and access considerations for patients, families,
visitors and staff
o Risks associated with additional travel and particularly with transferring
women during an emergency
o Staffing and recruitment
o Concern that proposals were financially driven or that more funding
should be sought to address the problems
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o More information required than was available to make an informed
judgement
3.2.3 Impact Assessment
Over recent years a number of Health Impact Assessments (HIA) and Equality
Impact Assessments (EQIA) have been undertaken as part of service planning.
These include the HIA and EQIA for the public consultation on the temporary
changes to Women’s and Maternity Services in North Wales; the decision to transfer
babies to Arrowe Park Hospital, Wirral for longer term and complex Intensive Care;
and the SuRNICC business case process. All of these assessments provide
valuable information on the North Wales population and more specifically on those
who use Maternity and Neonatal services. These assessments and others such as
the Quality Impact Assessment will be considered, reviewed and refreshed as part of
future work in developing the Women’s Strategy.
3.2.3.1 Key Themes from Health Impact Assessment
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Impact of increased travel distance and time for health care professionals,
the Welsh Ambulance Service Trust (WAST) and service users
Impact of change on vulnerable groups in the population of North Wales
3.2.3.2 Key Themes from Equality Impact Assessment (EQIA)
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Impact of choice, travel, transport and access to services as key issues for
patients, families, carers and staff. It is paramount that socio economic
issues, poverty and deprivation informs decision making
Consideration must be give to the impact of changes on disabled service
users including pregnant women with mental health problems or those who
suffer post natal depression
Welsh Language need to ensure there is access for families to communicate
in the medium of welsh
3.2.4. Ongoing feedback from women – “Did we deliver?”
The following two questions are asked of all women across North Wales who have
given birth;
1. Our aim is to prepare you and your partner to begin parenting feeling
confident and well supported to care for your baby. Did we manage to do
this?
2. It is important to us that you are treated with kindness and respect. Did we
manage this?
A snapshot from August 2016 showed that response rate varying from 40% to 84%
with the more than 95% of respondents happy with the care they received.
Feedback included comments such as “had a fantastic experience on the MLU”;
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“during labour Midwives explained everything to me beforehand, listened and
supportive”; and “felt supported by all the staff, and helped develop my confidence in
breast feeding”. There is also the opportunity for other comments / suggestions to
be considered, these include “a better understanding of pain relief after birth”, “to be
slightly more supported for breastfeeding”, and “waiting for clinics with kids / babies
for a long time is difficult. Please consider if you can make it better”.
Wider population and service user experience and feedback will continue to be
sought as we develop the Strategy. This will include an all Wales survey to evaluate
women’s views of antenatal services and how current service provisions prepare
women for labour, birth and parenting. This survey will aim to answer the question
’how can community midwifery services support women to feel confident for birth
outside an obstetric unit’. The outcome of the survey will be available in May 2017.
3.3 Staff Feedback
We have engaged with staff through drop in sessions as part of the SuRNICC
Business Case. This also considered the impact on Maternity services. Key
messages we received from staff included:
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Need for families to have access to welsh speakers
Any increase travel for staff and service users could potentially impact on care
Having a clear vision for the future service will improve recruitment
Services should be provided as close to home as possible
If staff have the opportunity to say how services should be developed they will
come up with the things we have to change
All staff should be treated with dignity and respect
Staff views and feedback will be essential to the future development of the Women’s
Strategy; an engagement plan will identify forums and ways in which this can be
gathered as we move forward.
3.4 Relevant Evidence base, Quality Standards & Outcome indicators
There is a plethora of evidence, quality standards and outcome indicators relating to
maternity and neonatal care which will be considered in developing the Strategy.
For the purpose of this Framework only the following key documents will be
considered in detail / referenced. A full list of evidence and reference documents
can be found in appendix 1.
3.4.1 A Strategic Vision for Maternity Services in Wales
‘A Strategic Vision for Maternity Services in Wales 2011’ sets out the strategic
context for maternity services in Wales. Tackling inequities in terms of access to and
the outcomes from maternity services in Wales is the main focus. The North Wales
Maternity Strategy Delivery plan sets out to ensure that every woman in North
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Wales, irrespective of her location, social background, circumstance or ethnicity, has
access to and receives safe high quality care, as close to home as possible.
There are five key themes for action to achieving this vision for maternity services;
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Place the needs of the mother and family at the centre so that pregnancy and
childbirth is a safe and positive experience and women are treated with dignity
and respect
Promote healthy lifestyles for pregnant women which have a positive impact
on them and their family’s health
Provide a range of high quality choices of care as close to home as is safe and
sustainable to do so, from midwife to consultant-led services
Employ a highly trained workforce able to deliver high quality, safe and
effective services
Are constantly reviewed
3.4.1.1 Performance Measures
The strategy sets out a number of measures through which we can judge the
performance and impact of our services, as follows 
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Caesarean Section rates
Proportion of women whose initial assessment has been carried out by 10
completed weeks of pregnancy
Rates of women with existing mental health conditions who have a care plan in
place
Percentage of women and partners who said they were treated well by the
maternity services
Rates of women who gave up smoking, drinking more than 5 units of alcohol,
gain no more than the recommended weight, gave up substance misuse
Staffing levels
Normal Birth Rates for the period
Proportion of babies with a birth weight below 2.5 kgs
Proportions of babies exclusively receiving breast milk at 10 days following
birth
Proportion of women and their partners who felt confident to care for their baby
% of women who smoke during pregnancy
- Drink 5 units or more/wk
- Have a BMI of 30 or more
- Misuse substances
Maternity unit closures
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3.4.2 Prudent Maternity Care
Over the past 6 months the Chief Nursing Officer for Wales has commissioned a
piece of work across Wales on developing prudent maternity care, with
recommendations due later this year.
Preliminary work has also commenced on developing ‘Prudent Obstetric’ care which
is in the discussion stage.
There is strong evidence that investing in early intervention, prevention and support
as early as possible leads to significant improvement in outcomes as well as savings
across the public sector. If maternity care services can reach and manage higher
risk groups of women in the antenatal period this will support and strengthen the
promotion of healthier pregnancies which could lead to less premature births and
poorer maternal and infant health outcomes, thereby reducing demand on neonatal
and paediatric services in the short to medium term.
The future service planning of maternity services also needs to reflect the Welsh
Governments requirement that 45% of pregnant women are offered a low-risk,
midwifery led environment for birth, reflecting the Prudent Maternity Care principles.
The number of women who could safely give birth in a midwife led setting is
important but it has to be seen as an end outcome that is affected by many other
factors, not least the provision of high quality antenatal care.
3.4.3 All Wales Neonatal Standards
The All Wales Neonatal Standards 2013 reflect the BAPM document and guidelines
from the ‘Baby Charter’ (Bliss 2011) are key standards for neonatal care. They are
currently being reviewed and are backed by greater requirements for collection of
outcome data and evidence of effectiveness. They seek to ensure that babies and
their families receive the best care possible, rather than best care, locally available.
Meeting these standards is the single most important driver in reconfiguring services
and centralising the North Wales neonatal intensive care service in the SuRNICC at
YGC. The standards cover the following areas –
1. Access to Neonatal Care
2. Staffing of Neonatal Services
3. Facilities for Neonatal Services, Including Equipment
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4. Care of the Baby and Family / Patient Experience
5. Transportation
6. Clinical Pathways, Protocols, Guidelines and Procedures / Clinical
Governance
7. Education and Training / Clinical Governance
3.4. National Neonatal Audit Programme (NNAP)
Along with the Neonatal Standards the National Neonatal Audit programme
(Healthcare Quality Improvement Partnership and the Royal College of Paediatrics
and Child Health) aims to improve the standard of care. The NNAP 2016 Annual
report on 2015 data looked at 10 areas of care, which includes specific areas
identified in the benefits table below:
 Temperature on admission to the neonatal unit
 Antenatal steroids
 Retinopathy of Prematurity Screening
 Mother’s milk at discharge
 Consultation with parents within 24 hours of admission to the unit
 Neonatal unit transfers
 Clinical follow-up at 2 years of age
 Bronchopulmonary Dysplasia (BPD)
 Recording of bloodstream and cerebrospinal fluid cultures
 Prevalence of Central Line-associated Bloodstream Infections
3.5 RCOG / Royal College of Midwives Safer Childbirth Report 2007
Update of the following documents is due for publication during November which will
be critical in assessing services against key standards and in shaping the Strategy:


Providing Quality Patient Care – Framework for Maternity Standards
Providing Quality Patient Care - Gynaecology Standards
Providing Quality Patient Care – Obstetrics and Gynaecology
3.6 RCOG Report – Options appraisal of Maternity Services at Betsi Cadwaladr
University Health Board, Wales.
The recent RCOG report concluded that at the time of the visit ‘Obstetric, obstetric
anaesthetic, neonatal, paediatric services provided by BCUHB were providing a safe
level of care’, There were a number of recommendations which will be considered as
part of developing the Strategy and have been included in the strategic principles.
Examples include normalisation of maternity care, which continues to be developed
in line with national recommendation; midwifery led care continues to be developed
as a core part of giving women choice; development of the non-medical workforce
beyond its current role; training needs for midwives and doctors creating a
supportive learning environment and Continued clinical leadership development
18
16.209.2 Appendix 3
3.7 Current Provision & Performance
3.7.1 Number of Birth in North Wales
The current number of births in North Wales is set out in the table below Hospital
2012
2013
2014
2015
Ysbyty Gwynedd
2,187
2,054
2,009
2,046
Glan Clwyd
2,403
2,273
2,246
2,039
Wrexham Maelor
2,706
2,593
2,646
2,642
Totals
7,296
6,920
6,901
6,727
In addition, approximately 7% (500 – 600 births) of pregnant women from North
Wales give birth at the Countess of Chester annually. In 2015/16 this number
increased and there were 625 births. Between 25 – 30 women from South Gwynedd
choose to give birth in Bronglais Hospital.
3.7.2 Midwifery-led Care
A key standard is to have initial assessment by a midwife by Week 10. Currently we
are reporting performance of 81% for a rolling 12 month period (85% in month in
September 2016), with the health Board aiming to deliver 87% by March 2017.
There is no national target set for this measure, and BCU has one of the highest
rates in Wales.
Rolling 12 Months - Initial Assessment by Week 10
Measure 2 - Initial Assessment by Week 10
100.00%
100.0%
90.00%
90.0%
80.00%
80.0%
70.0%
70.00%
60.0%
60.00%
50.0%
50.00%
40.0%
Jul-16
Sep-16
May-16
Jan-16
Mar-16
Nov-15
Jul-15
East
Sep-15
May-15
Jan-15
Central
Mar-15
Nov-14
Jul-14
West
Sep-14
May-14
Jan-14
BCU
Mar-14
Nov-13
Jul-13
Sep-13
May-13
Jan-13
Mar-13
40.00%
BCU Rolling 12
West Rolling 12
East Rolling 12
Linear (BCU Rolling 12)
Central Rolling 12
19
16.209.2 Appendix 3
Midwifery-led Units
Each of the District General Hospitals now have alongside midwifery-led units, YG
being the last unit to become operational The number of MLU births vary across
North Wales, with Wrexham having the highest number and percentage of births as
shown below.
30
25
20
East
15
Central
10
West
5
BCU
0
May
June
July
August
The percentage and number of women giving birth in a Free Standing MLU and
home births is currently 1.4%.
Promoting Normality - The Health Board has recently been successful in appointing
its first Consultant Midwife who will support and promote the normality agenda in
North Wales. The recommendation is for all Obstetric Units to have 1wte (whole
time equivalent) Consultant Midwife to 900 low risk women to support normality,
reduce medical intervention and caesarean section rates (Standards for Maternity
Care RCOG 2008). The target is for 45% of women to start labour outside an
obstetric unit. The current percentage of women who give birth outside an obstetric
unit is 18% again with variation across the units with east and centre at 18% and the
west at 15%.
Birthrate Plus - Birthrate Plus is a recognised workforce tool used in maternity
services endorsed by NICE, which calculates the midwifery staffing requirements for
the service provided. North Wales is currently Birthrate Plus compliant. This has
recently been reviewed with final requirements for North Wales being available by
December 2016. Currently BCU employs 280 wte midwives and 31 wte Maternity
Support Workers as a 10% recognised skill mix introduction.
Maternity services should develop the capacity for every woman to have 1:1 care in
established labour at all times (standards for Maternity Care RCOG 2008). BCU is
fully compliant with 100% of women receiving 1:1 care.
Breast Feeding - The Midwifery and Neonatal Units have all achieved stage 2 and 3
of the UNICEF accreditation across North Wales, however we still have low rates of
breast feeding initiation and there is a steep drop-off in the number of mothers’
breastfeeding in the first 10 – 14 days after birth. The proportion of babies’ breast
feeding at birth was reported at 50% for the 12 months ending August 2016. Babies
20
16.209.2 Appendix 3
breast feeding at 10 days old shows a static trend at 29%. Babies’ breast feeding at
6 weeks is also static at 20%.
3.7.3 Obstetrics
The majority of obstetrics is carried out by consultants who practise both obstetrics
and gynaecology. As previously stated this Framework will only consider Obstetrics,
but the overarching Women’s Strategy will address all Women’s health services. As
identified earlier we should be working to 45% of women starting labour outside of a
Consultant Led Unit. Currently 82% of women give birth in an obstetric unit
Consultant Presence on Labour ward is a key standard from the ‘Safer Childbirth 2007. Units with less than 2500 births require 40 hours / week which applies to YG
and YGC, with both units compliant. WMH with in excess of 2500 births is compliant
with 60 hours / week cover.
Caesarean Section – The target here is a maximum of 25% c- section rate. BCU
rate is reported at 26% for the rolling 12 months, but there is monthly variation. Each
unit has an action plan to reduce the number of C-Sections and regularly reports
against these actions.
BCUHB
26.0%
Rolling 12 Months
YG
25.8%
YGC
27.5%
Measure 1 - C-Section Rates by Sites
WMH
24.9%
Rolling 12 Months - C-Sections Rates
35.0%
40.0%
30.0%
35.0%
25.0%
30.0%
25.0%
20.0%
20.0%
15.0%
15.0%
10.0%
10.0%
5.0%
5.0%
Central
East
BCU Rolling 12
West Rolling 12
East Rolling 12
Linear (BCU Rolling 12)
Jun-16
Central Rolling 12
Aug-16
Apr-16
Feb-16
Oct-15
Dec-15
Jun-15
Aug-15
Apr-15
Feb-15
Oct-14
Dec-14
Jun-14
Aug-14
Apr-14
Feb-14
Jul-16
Sep-16
May-16
Jan-16
Mar-16
Nov-15
Jul-15
Sep-15
May-15
Jan-15
Mar-15
Nov-14
Jul-14
West
Sep-14
May-14
Jan-14
Mar-14
Jul-13
Sep-13
May-13
Jan-13
Mar-13
Nov-13
BCU
Dec-13
0.0%
0.0%
21
16.209.2 Appendix 3
Maternity Unit Closures – Between January and October 2016 there have been 5
unit closures ranging from 2 hours to 11 hours. Analysis of the closures shows that
they generally happen out of hours and at weekends. Generally this is due to high
acuity levels and / or staff sickness.
There were 68 In-utero transfers between January 2016 and September 2016. Best
practice is for women to give birth in a unit where there is direct access to a neonatal
unit able to provide an appropriate level of care
Site
< 27 weeks (Out
of Area &
planned)
7
> 27 weeks
YGC
1
1
WMH
10
18
North
Wales Total
18
50
YG
31
Comment
Total / site
Transfer to YGC
as per protocol
38
2
17 to YGC
1 to Chester
28
68
3.8 Other Performance Indicators
Smoking - The proportion of women that smoke during pregnancy has shown little
change over the last 2 years, typically reporting 16 – 17%. The health board has a
trajectory in place to reduce the number of women smoking at 36 -38 weeks to 14%
by the end of 2016 /17.
BCUHB
YG
YGC
WMH
17.8%
17.6%
19.9%
16.5%
Rolling 12 Months
Proportion of Women who: Smoke during Pregnancy
12 Months Rolling - Proportion of women who : Smoke during
Pregnancy
35.0%
25.0%
30.0%
20.0%
25.0%
15.0%
20.0%
10.0%
15.0%
5.0%
10.0%
0.0%
5.0%
BCU
West
East
Jun-16
Aug-16
Apr-16
Feb-16
Oct-15
Dec-15
Jun-15
Central
Aug-15
Apr-15
Feb-15
Oct-14
Dec-14
Jun-14
Aug-14
Apr-14
Feb-14
Oct-13
Dec-13
0.0%
BCU ROLLING 12MTHS
WEST ROLLING 12MTHS
CENTRE ROLLING 12MTHS
EAST ROLLING 12MTHS
Linear (BCU ROLLING 12MTHS)
The proportion of women that gave up smoking during pregnancy is reported at 2.7%
for the past 12 months.
22
16.209.2 Appendix 3
Low Birth Weight – Singleton live births less than 2.5kgs (LBW). The rolling 12
month position is 7.41% (this includes multiple births).
BCUHB
YG
YGC
WMH
7.41%
7.17%
6.69%
8.07%
Rolling 12 Months
Proportion of babies weight below 2.5kg
12 Month Rolling Data - Proportion of babies weight below
2.5kg
14.00%
9.00%
12.00%
8.00%
7.00%
10.00%
6.00%
8.00%
5.00%
4.00%
6.00%
3.00%
4.00%
2.00%
1.00%
2.00%
West
East
All Wales Avg. 2014*
BCU
West
Central
East
All Wales Avg. 2011*
Linear (BCU)
Jun-16
Aug-16
Apr-16
Feb-16
Oct-15
Dec-15
Jun-15
Aug-15
Apr-15
Feb-15
Oct-14
Dec-14
Jun-14
Aug-14
Apr-14
Feb-14
Jul-16
Sep-16
May-16
Jan-16
Mar-16
Nov-15
Jul-15
Sep-15
May-15
Jan-15
Mar-15
Nov-14
Jul-14
Central
Sep-14
May-14
Jan-14
Mar-14
Jul-13
Sep-13
Nov-13
May-13
Jan-13
Mar-13
BCU
Dec-13
0.00%
0.00%
The rates of women with existing mental health conditions who have a care plan in
place has typically been reported at 5 – 6% each month which is a slight increase in
trend from previous years. Compliance with a Mental Health care plan in place for
these women is reported at 50% for the last 12 months.
Other key indicators of health show the following 




The proportion of women that reported drinking 5 units or more at booking
was 81%, which is an increasing trend over the last two years.
The proportion of women reported as gaining no more than the recommended
weight during pregnancy is 69%. The proportion of women reported as
having a BMI of 30 or more at initial assessment was reported at 25%.
The proportion of women reported as misusing substances are reported at
less than 1%
Normal Birth Rates for the period are reported at 59% which is a static trend
over the past 2 years
Stillbirth Rate – Between 2013 and 2015, for 51% of stillbirths the cause of
death was unknown. Screening and monitoring in pregnancy are used to
identify high risk pregnancies so that appropriate clinical management can be
provided – All Wales Perinatal Survey, Annual Report 2015. There has been
a significant reduction in the stillbirth rate in North Wales (Welsh Initiative for
Stillbirth Reduction). In 2014 we reported a stillbirth rate of 4.45 per 1,000
registrable births. In 2015 this reduced further to 3.53 per 1000 of total births,
compared with a Wales average of 4.83.
23
16.209.2 Appendix 3
3.9 Neonatal & Paediatrics
Approximately 10% of all babies born receive some level of neonatal care ranging
from a small number of hours to many weeks.
Existing Arrangements for North Wales - The North Wales neonatal service is
provided across 2 clinical networks, the Wales Neonatal Network and the Cheshire &
Merseyside Neonatal Network (CMNNN). The CMNNN provide neonatal intensive
care (NIC) to babies born at or less than 27 week’s gestation. Once the SuRNICC is
fully established the gestational age threshold for transfer will drop to 26 weeks.
Networks are composed of 3 types of unit (BAPM 2010):
1. Special Care Units (SCU): These provide special care for their own local
population. They also provide, by agreement with their neonatal network, some
high dependency services.
2. Local Neonatal Units (LNU): These provide special care and high dependency
care and a restricted volume of intensive care (as agreed locally) and would
expect to transfer babies who require complex or longer-term intensive care to a
Neonatal Intensive Care Unit.
3. Neonatal Intensive Care Unit (NICU): These are larger intensive care units that
provide the whole range of medical (and sometimes surgical) neonatal care for
their local population and additional care for babies and their families referred
from the neonatal network in which they are based, and also from other networks
when necessary to deal with peaks of demand or requests for specialist care not
available elsewhere. Many will be sited within perinatal centres that are able to
offer similarly complex obstetric care. These units will also require close working
arrangements with all of the relevant paediatric sub-specialties.
Low Dependency or Transitional Care can be delivered in 2 service models, either
within a dedicated Low Dependency Care ward or within a postnatal ward. In either
case the mother must be resident with her baby and providing care. Care above that
needed normally is provided by the mother with support from a midwife or maternity
support worker who needs no specialist neonatal training. The model for north Wales
is care on the postnatal ward, but there is variation across the 3 maternity units on
the amount of Transitional Care provided.
The current neonatal service falls short of the required standards - In particular
access to neonatal services (standard 1) and the correct level and number of staff
(standard 2). Over the past 12 months there has been significant success in
recruiting to medical and neonatal nursing posts, improving our compliance with the
standards. Access and workforce are the main factor in other failings in meeting the
standards, including local access to the service being limited by frequent unit
closures due to lack of staff and a limited transport service. The frequency of
24
16.209.2 Appendix 3
closures has a direct impact on the ability of the 3 obstetric units to remain open.
Facilities and equipment are also below the standards, including inadequate clinical
space and insufficient accommodation for families.
The solution
Development of a Sub-Regional Neonatal Intensive Care Centre at YGC
supported by SCUs at YG and WM.
The SuRNICC will provides all the facilities and skills of an LNU but through
agreement with the Wales Neonatal Network will operate in an enhanced
mode and provide cares for younger infants and those with more complex
clinical needs than a regular LNU.
The SuRNICC development will provide improvements to the YGC maternity
unit, including: 4 bed transitional care unit
 Additional toilet facilities
 Additional en-suite delivery room
 Bereavement suite (supported by SANDS)
 Improvement to Maternity Outpatient Assessment Unit (MOAU) and
waiting areas
Once the SuRNICC model is fully implemented across North Wales it is estimated
that 25 babies per annum will still receive their care outside of North Wales (this
includes babies less than 26 weeks and those requiring surgical, cardiac,
neurological intervention and for maternal reasons). Babies who no longer need to
receive care out of North Wales will be repatriated to local units as soon as clinically
appropriate.
Currently the 3 Acute Hospitals in North Wales provide 24 / 7 neonatal care at
different care levels. As part of implementing the SuRNICC model YGC is currently
developing capacity to take more of the North Wales Neonatal Intensive Care (NIC)
and provide all High Dependency (HD) and Special Care (SC) for their local
population. The neonatal rota / service at YGC have recently been separated from
the General Paediatric rota / service, and now provide a dedicated Consultant and
Junior (Tier 1) medical rota. There is some cross cover for Middle Grade medical
staff (Tier 2) and there is a dedicated Advanced Neonatal Nurse Practitioner (ANNP)
rota. The North Wales Neonatal Transport Service is also located at YGC.
Although WMH provides some intensive care this will reduce as the plans to
transition to the new SuRNICC model are fully implemented by March 2018. WMH
25
16.209.2 Appendix 3
will continue to provide all HD and SC for their local population. YG provides some
HD care and all SC for their local population. In line with national standards YG and
WMH will each have 1 resuscitation and stabilization cot. For those babies requiring
transfer to the SuRNICC or a NICU this will be done by either the 12 hour North
Wales Transport Team or the Cheshire & Merseyside Transport Team which
provides 24 / 7 cover for time critical transfers. The medical cover for both WMH and
YG units is shared with general paediatrics which will continue and is in line with
national standards.
The new service will provide the following fully compliant staffed cots:
Site
Intensive Care and
Stabilization Cot
HD
SC
Total
SuRNICC
5+1
5
9
20
YG
0+1
1
8
10
WM
0+1
2
9
12
North Wales
Total
5+3
8
26
42
Current performance against standards
The Wales Neonatal Network has a key role in overseeing the monitoring of the All
Wales Neonatal Standards. The Health Board undertakes a review of neonatal
capacity on a 6 monthly basis. It provides assurance to the North Wales Service and
Wales Neonatal Network Steering Group on progress being made against all the
standards. A detailed description of the model, identification of standards and
compliance
can
be
found
in
the
Outline
Business
Case
http://www.wales.nhs.uk/sitesplus/861/page/84322
Standard 1 – Access to Neonatal Care will be considered in more detail for the
purpose of this framework due to the direct impact on the ability of the Maternity Unit
to operate efficiently.
Compliance: There is partial compliance with this standard, as we currently have to
transfer mothers and babies more than 27 weeks gestation out of North Wales to
receive their care due to insufficient staffed capacity within North Wales.
Improvements have been made due to networking across the 3 North Wales Units
and recent recruitment but we still see high numbers of unit closures and transfer of
activity to England.
26
16.209.2 Appendix 3
Table: Number of Closures of North Wales Neonatal Units
Site
2015 - 2016
Number of Closures
1
12
23
36
YG
YGC
WMH
Total
2015-16
Hours of Closures
110
347
1293
1750
The most frequent reasons for closure are: Insufficient cots to meet the number of babies (YGC), insufficient nursing staff
(WMH) and no intensive care cots (YG)
 Insufficient nursing staff in WMH accounts for approximately 60% of closures
in Wrexham
 The main reason for closure across North Wales is insufficient nursing staff
which accounts for approximately 56% of total instances of closure.
The closure of the neonatal units has a direct impact on obstetric services. When
there are insufficient cots, women are transferred in-utero to a unit where there is an
available cot at the appropriate care level.
The 3 North Wales units act as a
network and at times women and babies are transferred between our units, but we
continue to see a number of women over 27 weeks gestation being transferred to
England to access appropriate levels of care.
Avoidable In-utero Transfers 2015/16
Number of Transfers
From
To
20
2
10
WM
YGC
BCU
YGC
WMH
Cheshire & Merseyside Network
NB. There were also 19 transfers from YG to YGC for women less than 32 weeks gestation
as per the agreed pathway
Following full establishment of the SuRNICC more babies will receive all their care in
North Wales as we plan to care for all babies born at more than 26 weeks gestation,
other than those requiring specialist input such as surgery or cardiac care. The table
below is an average taken over the past 30 months and shows the expected positive
impact of the SuRNICC.
YG
YGC
WMH
English
Units
Total
Current model
195
270
216
58
739
SuRNICC
195
344
176
24
739
variance
0
+74
-40
-34
27
16.209.2 Appendix 3
National Neonatal Audit Programme
The SuRNICC business case considered 5 of the 10 audit areas:




Consultation with parents with 24 hours of admission – currently 66%
Mothers milk at discharge – currently 26.8%
Clinical follow-up at 2 years of age – currently follow up is poor
Temperature taken within 1 hour of admission – Currently 85%
Neonatal Transfers
The 2016 report has identified 3 areas which demand particular attention:
 2-year follow up
 Temperature on admission to the neonatal unit
 Recorded consultation with parents within 24 hours of admission to the unit
Improving performance against all audit areas have been identified in the Benefits
Realisation Strategy http://www.wales.nhs.uk/sitesplus/861/page/84471 as part of the
SuRNICC Implementation and performance monitoring Framework.
28
16.209.2 Appendix 3
4 .HIGH LEVEL MAPPING OF SERVICES, ESTATE AND RESOURCES
The Maternity Service will have a 3 site service delivery model for Obstetrics,
Midwifery and Gynaecology Services located at YG, YGC and WMH.
Each location includes:
 A Consultant led Obstetric Unit with an alongside Midwifery Led Unit
 Antenatal and post natal unit
 Maternity Outpatient Assessment Unit (MOAU)
 Emergency Gynaecology Service (including Early Pregnancy Assessment
Unit)
 Gynaecology Surgery Service - Inpatient and Day-case
 District General Hospital (DGH) -based Outpatients Clinics (on all 3 sites for
Gynaecology; YG and WMH for Antenatal Clinics)
 A network of community based clinics across North Wales
 Community Midwifery
 Free Standing Midwife-led units at Denbigh, Dolgellau, Towyn and Pwllheli
These services will form part of a wider network of services as shown in the diagram
below Network of Services
(RCOG – High Quality Women’s Health Care: a proposal for change)
Tertiary
Care
Community
Clinics
FMLU
YG Obstetric &
SCU
AMLU
YGC –
Obstetric &
SuRNICC
Primary
Care
AMLU
WMHObstetric
& SCU
AMLU
FMLU
FMLU
FMLU
Neonatal
Outreach
Midwife
Community
Midwife
Home
Births
29
16.209.2 Appendix 3
4.1 Birth Environment - One of the key issues regarding the current service is the
Birth Environment - There is much evidence to support the view that the environment
in which a woman gives birth is very important. Each of units undertakes the
National Childbirth Trust (NCT) Better Birth Environment Audit each year. The right
birth environment is being increasingly recognised for the important role it plays in
women’s chances of having a normal birth (NICE Intrapartum Guidelines).
Studies have shown that normal labour requires specific conditions - that the
labouring mother feels private, safe and unobserved. These factors keep her as calm
and relaxed as possible, and her adrenaline levels low. Conversely, if she is not
feeling private, safe and unobserved in labour, her adrenaline levels will increase,
slowing labour and decreasing blood and oxygen supply to the baby. A Cochrane
review of the use of birth pools found that water immersion during the first stage of
labour significantly reduced epidural / spinal analgesia requirements, without adversely
affecting labour duration, operative delivery rates, or neonatal wellbeing. One trial
showed that immersion in water during the second stage of labour increased women's
reported satisfaction with their birth experience.
Whilst ‘feeling private, safe and unobserved’ apply to all women whether they give
birth within an obstetric or a midwife led unit, as more midwife led units are being
opened it will be important to ensure that they are fully equipped to provide optimum
opportunity for women to have a normal birth.
The Welsh Government also acknowledges the importance of the environment in
optimising normal birth:‘Painting walls and adding soft furnishings in Birth Centres will not be enough
to encourage women to use them and midwives to work in them. Privacy and
peace, plumbed in birth pools and adequate staffing should be considered as
essential requirements for a fully functioning Birth Centre and this requires
investment.’
Minimum Requirements for a Midwife-led Unit In order for women that women feel
‘private, safe and unobserved’:


There should be access to the MLU without going into an obstetric unit;
All facilities should be provided within the MLU so that new mothers are not
transferred to a postnatal ward should they wish to stay overnight.
30
16.209.2 Appendix 3
Essential facilities
 1 room per 350 births based on 45% of women starting labour outside an
obstetric unit this would require each of our units to have additional midwife
led beds:Site
YG
YGC
WMH





Total Number
of Births
2100
2300
2700
45%
945
1035
1215
Current ML
Beds
2
2
2
Required ML
Beds
2.7
2.96
3.5
Each room will have a plumbed in birth pool that enables women to be fully
immersed in water
Shower facilities
A double room for postnatal overnight stay (based on 1/4 of women wanting
this facility)
Enough space to enable safe evacuation from the pool in an emergency
Facilities for making light refreshments (i.e. tea and toast)
4.2 Centralized Antenatal Clinics – YG and WMH both have antenatal clinics
located in the DGHs. A similar arrangement would be needed for YGC in order to
improve patient flow and access to a wider range of services. This may result in a
review of the current community provision.
31
16.209.2 Appendix 3
5. WORKFORCE ISSUES
We need to ensure that all staff providing services to women and babies are:





Well informed
Appropriately trained
Involved in decisions which affect them
Treated fairly and consistently
Provided with an improved and safe working environment
5.1 Maternity Services
Midwifes - Recruitment has been successful to all midwifery posts, although there is
still some use of Bank / Agency until all staff take up post. Midwifery Trainees are
attached to each of the 3 units, with 3rd Year students having just being reallocated
to YGC following a temporary withdrawal. There is an established programme for
Maternity Support Workers (MSW) training which allows for a ratio of 90:10 Midwife
to MSW. There are well established links with the Local Supervising Authority.
Medical Staffing - There have been significant pressures around the medical
workforce, with previous unacceptable high levels of locum / agency use. The
situation is improving with ongoing recruitment to consultants with resident on call
duties which partly address the gaps in the national shortage of the Tier 2 medical
staff and helps provide increased consultant led care during out of hours. Each of
the 3 consultant led-units is recruiting to 4 additional consultant posts. A number of
staff have already taken up post whilst other posts are being recruited to, these
appointments will reduce the dependency on locum and agency usage.
At present the Deanery requires doctors in training to be allocated to 2 sites in North
Wales which are YG and WM. There is a shortage of doctors to fill all the training
grade posts at both Tier 1 and Tier 2 with a high number of these remaining vacant.
5.2 Training compliance 2016
One of the requirements of the Special Measures Framework is to satisfy national
and statutory requirements for mandatory training within maternity services.
Improvements have been made in both Midwifery and medical staff compliance.
Midwifery Overall Compliance





Mandatory Training – 100%
Mentor Update Training – 100%
Triennial Reviews – 100%
Annual Supervisory Reviews – 100%
Performance Appraisal and Development Review (PADR) compliance – 100%
32
16.209.2 Appendix 3
Medical Overall Compliance
 Mandatory Training is currently 84% for all medical staff across the 3 sites.
There is a target to achieve 100% with Clinical Directors and Service
Managers supporting staff to attend relevant training via workshops or elearning

RCOG CTG e-learning training – 100% compliance was achieved in March
2016. Rolling programme for 2016/17 is being progressed, with a trajectory
100% compliance required by Feb 2017.
The Nursing & Midwifery Council (NMC) follow up review of the Local Supervising
Authority of Midwives (LSA) in Wales and Statutory Supervision in BCUHB
concluded on the 23/6/16 and confirmed that all rules relating to Statutory
Supervision were met and that Rules 7 & 9 was met promptly following their
Extraordinary Review in July 2015. A further LSA Annual Audit Review was
undertaken in September 2016. Again all Rules and Standards pertaining to
Statutory Supervision were met. A written Report will be available to the Health
Board in December 2016.
5.3 Neonatal Services (YGC)
Workforce issues in relation to development and implementation of the SuRNICC
has been a major part of the SuRNICC Business case plan. A Risk and Issues log,
Recruitment and Attraction Strategy, Training Needs Analysis and Communications
plan are available to support the work. A summary of the key area’s relating to
workforce are: Consultant recruitment – the requirement is for 7 consultants, with the Health
Board being successful in recruiting to 5 posts, this has facilitated the
separation from the general paediatric rota at YGC
 Tier 1 junior doctors – the requirement is for 8 doctors on a dedicated neonatal
rota, with the Health Board being successful in establishing this at YGC
 Tier 2 doctors – this is a shared 1:11 rota with Paediatrics, again requirement
has been achieved but there are still challenges with achieving this year on
year.
 Advanced Neonatal Nurse Practitioners (ANNP), the requirement is for 6 and 5
are in post. ANNPs are able to support both the Tier 1 and 2 rotas if required.
 Neonatal Nurses – Recruitment and / or training of nurses Qualified in
Speciality (QIS) is the highest risk relating to workforce, with mitigating actions
being successful to date. This will remain a high risk as the standard is that
70% of nurses should be QIS (17.5 nurses to recruit to)
 The North Wales Transport service is staffed by the consultants and ANNPs
supported by dedicated neonatal transport nurses. This service provides
transport for all neonates between the 3 North Wales units, all retrievals from
out of area and for attendance at regional centres for day case and
outpatients.
As part of the SuRNICC Attraction and Recruitment Plan, additional consideration is
being given to increasing the number of welsh speaking staff in line with the Welsh
Language Measure. Best practice and recommendations will be shared with
33
16.209.2 Appendix 3
Paediatric services. Additional information can be found on Neonatal Workforce at
http://www.wales.nhs.uk/sitesplus/861/page/85871
5.4 Paediatric Services
Medical staff provision for the neonatal units in YG and WMH is covered by the
General Paediatricians, with an identified lead consultant at each site. Advice and
support is being increased from the neonatal team at YGC as recruitment
progresses, this includes Consultant, ANNP and Lecturer Practitioner and transport.
5. 5 Obstetric Anaesthetics
Recommendations for the anaesthetic staffing of consultant led maternity units in the
UK are described in a joint document by the Obstetric Anaesthetists Association
(OAA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI)
entitled ‘OAA / AAGBI Guideline for Obstetric Anaesthetic Services 2013’.The
following recommendation is made for consultant staffing :
‘As a basic minimum there must be 12 consultant sessions per week to cover
emergency work on delivery suite. Scheduled obstetric anaesthetic activities (e.g.
elective Caesarean Section lists and clinics) require additional consultant sessions
over and above the 12 for emergency cover.’
A proposal to increase consultant obstetric anaesthetist emergency cover for the
delivery suite in YG has recently been approved which will make the 3 units
compliant with national recommendations.
34
16.209.2 Appendix 3
6. INITIAL IDENTIFICATION OF PRINCIPLES FOR FUTURE STRATEGY
6.1 Principles
The following section identifies the principles which we believe provide the
foundations for delivering a ‘good maternity service’ and which puts women and their
babies at the centre of what we do.
All pracitioners working with or on behalf of women to deliver Maternity Services and
care of the newborn need to take responsibility for ensuring everything possible is
done to seek early intervention and to prevent unnecessary escalation to a higher
level of care. All services need to consider the needs of the women and baby to
ensure quality, safe care and support is provided. The principles have been mapped
agaist the key themes and actions of the Maternity Vision for Wales and proposed
outcomes we seek to deliver.
35
16.209.2 Appendix 3
Key Theme
Principles
Place the needs of the mother and 
family at the centre so that
pregnancy and childbirth is a safe
and positive experience and
women are treated with dignity and
respect



Promote healthy lifestyles for 
pregnant women which have a
positive impact on them and their 
family’s health


No-one will be discriminated
against on the grounds of
pregnancy,
age,
ethnicity,
religious belief, faith, culture,
class, sexual orientation, gender,
language or disability
Women’s needs come first
Continuity of antenatal and post
natal care
Building Resilience
Focus on the first 1000 days
from conception
Improving health and tackling
inequalities
A shared responsibility for
achieving better outcomes for
women, babies and families
Public education on staying
healthy throughout the life cycle
Key Action










Outcome
Support for new families
Improve women’s experience
of care
Information on choice / place
of birth
Healthy and well supported new
familes
Upstream prevention
Smoking Cessation
Breast Feeding
Healthy maternal weight
Good maternal nutrition
Folic Acid
Information given to women,
their families and the wider
public on a range of areas
e.g. stillbirth
Healthy mothers and babies and
fewer premature and low birth
weight deliveries
Effective
engagement
service users
with
Reduction in the rates of still birth
and infant mortality
Improved health and
health and well being
mental
Every child has the best start in
life
Reduced number of ACEs
Provide a range of high quality 
choices of care as close to home
as is safe and sustainable to do 
so, from midwife to consultant-led
services

Care closer to home, where 
clinically appropriate
Apply the principles of prudent
health care
Identify interventions which will
Improved opportunities for better
long term health and well being
into adulthood
Review
of
current Women have access to a range
organisation and delivery of of safe high quality maternity
services against the vision services that meet their needs
and themes set out in the
National strategy – reflection
needs of the local community
36
16.209.2 Appendix 3




Employ a highly trained workforce
able to deliver high quality, safe
and effective services




Services are constantly reviewed



have the most impact on
population outcomes
Midwifery led care continues to
be developed as a core part of
giving women choice
Services are responsive to
women, partners and babies
needs proportionate to the level
of need and risk
Timely access to services
Provision of an environment fit
for purpose in a range of care
settings
Development of the non-medical 
workforce beyond its current role 
Training needs for midwives,
doctors and nurses create a
supportive learning environment
Continued clinical leadership
development
Multi-disciplinary
and
interagency working
Health care must be consistent 
and evidence based
Views of women and families will
be sought, listened to and
considered
in
re-designing 
services
Normalisation of birth continues
to be developed in line with
national recommendations
to inform the development of
the Women’s strategy and
local service improvement
plans
Workforce Planning
Research and development
Highly trained and educated
workforce able to deliver safe,
high quality maternity care
Evidence based maternity and
neonatal care is developed and
implemented
Introduction of the National Maternity services provide safe
outcome
measures
and high quality care
performance indicators for
services
Carry out regular clinical
audits, including participating
in national audit activity
37
16.209.2 Appendix 3
6.2 Identification of Service Components and Levels of Care
Women and babies may have different levels of need / care at different times across
a range of service areas. Having a graduated approach ensures that support
needed will be appropriate and be delivered at the lowest level of intervention
needed. The ‘windscreen’ or ‘speed dial’ shows a diagram to demonstrate the
Continuum of Need / Intervention, against 4 broad categories. It is intended to
visually convey that women’s and the newborn needs change over a period of time
and that they may move across levels of need / intervention and back again.
Decision making needs to be informed by appropriate risk assessments, pathways,
guidelines and standards.
It is inevitable that many women and babies will move back and fore between levels
of care during pregnancy and during the post-natal period. The movement between
levels should happen seamlessly and regular review should ensure that the prudent
principle of ‘do only what is needed’ applies .
Level of intervention / support can change in line with level of need
LEVEL 2
LEVEL 3
UNCOMPLICATED
PREGNANCY
ADDITIONAL
CARE
LEVEL 4
Level 1
HEALTH
PROMOTION
PREVENTION
N
2
3
1
4
MORE
COMPLEX
CARE
38
16.209.2 Appendix 3
Level 1 – Health Promotion/ Universal
a) Service user engagement and feedback be sought and acted upon at all levels
b) Pregnant women receive continuity of care from a named midwife.
c) Midwife led units and community clinics are used as a hub for health promotion
activities.
d) Local public health services provide interventions to support weight mangement
during pregnancy for women with a raised body mass index (BMI).
e) Preparation for birth classes are available to all women in a location as close to
their home as possible.
f) Support for the emotional health & well being of mother, partner and family
g) Perinatal mental health services recieve timely referals from maternity service
professionals for women with serious pre exisiting mental health problems
Health Promotion education, advise , information and intervention will run
through all levels of care with the aim of prevention and early intervention at
every oppourtunity
Some of the key services components available at this levels of care are:Pre-Conception Advice
Families
First
Immunisation
Breast Feeding
Support
Emotional Health &
Wellbeing
Perinatal Mental Health
Training & Awareness
WARENESS
Social Services
Smoking
Cessation
Programmes
Alcohol & Substance Misuse
Awareness
Health Visitors
Preparation for birth and
parenting classes
Family Planning
Weight Management
Programmes
Flying Start
Welsh Initiative to
Reduce Still Births
Births
Promoting
Normality
Performance Indicators / Measures










Booking with Midwife by 10 completed weeks
Breast feeding rates
Flu Vaccination for pregnant Women
Pre-conception Folic Acid
Obesety – BMI (Key risk factor for still birth)
Teenage Pregnancy Rates (higher levels infant mortality)
Preparation of women and partners who feel confident to care for their baby
Women who drink 5 or more units of alcohol / week
Substance misuse dring pregnancy
Smoking rates
39
16.209.2 Appendix 3
Level 2 – Uncomplicated Pregnancy
a) There will be a Midwifery-led Unit co-located with the 3 Consultant-led Units
b) Women will have the choice for a home birth or in a Free Standing Midwifery-led
Unit
c) Community Midwifery Services provide local prudent care to support women to
be cared for in the community and to reduce admission to an obstetric unit.
d) Consultant Midwife to support normality
e) Bereavement services
f) Safeguarding
These components will also be provided at levels 3 and 4
Some of the key services components available at this levels of care are:Community
Midwifery
Free standing
Midwife Led Unit
Breast Feeding
Support
Home Births
Community Based
Scanning Facilities
Ante-Natal
Screening
Newborn
Screening
Timely Access to
Consultant Led Care
Midwife Led
Unit
Consultant
Midwife
Performance Indicators / Measures







All women have continuity of antenatal and post natal care from a named
midwife
45% of women will start their labour outside an Obstetric Unit
Number of Transfers from a MLU / FMLU / Home to an Obstetric Unit
All women will have 1:1 support in establish labour at all times
Birthrate plus – Staffing Acuity Tool
Breast feeding rates
Percentage of pregant women who are smokers at 36 – 38 weeks (Smoking is
a key risk factors for still birth).
40
16.209.2 Appendix 3
Level 3 – Additional Care
a) Each of the three Units will provide consultant obstetrics, early pregnancy
assessment units, Maternity Outpatient Assessment Unit (MOAU), high risk clinics,
obstetric anaethesics, scanning facilities, transitional care, neontal special care and
high dependency care, adult critical care
b) Obstetric services provide prudent care to support women
c) Local fetal medicine services will be provided at each site.
d) Community Perinatal Mental Health Services (Mental Health & Specialist Midwife)
e) Tier 3 Substance Misuse Services (Specialist Midwife)
f) Bereavement services
g) Safeguarding
These components will also be provided at level 4
Some of the key services components available at this levels of care are:Consultant
Obstetrics
Transitional
Care
Maternity Outpatient
Assessment Unit
Community Perinatal
Mental Health
Services
High Dependency
Neonatal Care
High Risk
Clinics
Local Fetal
Medicine
Adult Critical
Care
Obstetric
North Wales
Neonatal
Anaesthetics
Neonatal Transport
Special Care
HSC
Specialist Services –
Tier 3 Substance
Early Pregnancy
Misuse services
e.g. Diabetes
Assessment Clinic
Medicine
Clin
Performance Indicators / Measures











Emergency
Transport
Consultant Presence on Labour Ward
Inductions of Labour
Caesarean Section Rates
Obstetric Anaesthetic Staffing
Maternity Unit closures
Neonatal Unit closures
In-utero Transfers
Breast feeding rates including neonatal units
Low Birth Weight Babies
Still Birth Rates
Infant Mortality
41
16.209.2 Appendix 3
Level 4 – Complex & Specialist (Sub-Regional)
Some services may only be available at a single (or two) sites.
a) Neonatal Intensive Care provided in North Wales will be at YGC in the SuRNICC.
b) The North Wales Neonatal Transport Team will be co-located with the SuRNICC
for the retrieval, repatriation and all other transport of neonates e.g. baby needing
to attend an out patient appointment out of area.
Out of Area Tertiary Services
c) Tertiary Fetal Medicine (Liverpool Women’s Hospital)
d) Tertiary Maternal Medicine
e) Level 3 Neonatal Intensive Care Unit
f) Mother and Baby Units (Psychiatric support)
Services available at this levels of care:
Neonatal Intensive
Care Unit
A
Consultant
Obstetrics
SuRNICC
Transitional
Care
Maternity Outpatient
Assessment Unit
Community Perinatal
Mental Health
Services
High Dependency
Neonatal Care
Tertiary Fetal
Medicine
High Risk
Clinics
Local Fetal
Medicine
Emergency
Transport
Adult Critical
Care
Obstetric
North Wales
Neonatal
Anaesthetics
Neonatal Transport
Special Care
HSC
Specialist Services Tier 3 Substance
Early Pregnancy
Misuse services
Diabetes
Assessment Clinic
Medicine
Performance Indicators / Measures











Tertiary Maternal
Medicine
Consultant Presence on Labour Ward
Inductions of Labour
C-Section Rates
Obstetric Anaesthetic Staffing
Maternity Unit closures
Neonatal Unit closures
In-utero Transfers
Breast feeding rates including neonatal units
Very Low Birth Weight Babies
Low Birth Weight Babies
Still Birth Rates
42
16.209.2 Appendix 3
7. ENGAGEMENT WITH STAFF, SERVICE USERS AND PARTNERS
A detailed plan of engagement is being developed and will build upon best practice
which has already been in place. This will include:
Senior staff from the Women’s Division visit each of the 3 units offering a drop in
session for all staff. Future sessions will include members of the Planning Team
who will have the oppourtunity to listen to staff and include their contributions into
developing the Strategy.
Following the Senior Clincal and Operational Leads engagement event at the end of
October 2016, each of the sites will be using existing programme teams and forums
as well as larger events to engage with staff on ‘what a good, quality, safe and
sustainable service’ for women will look like as well as what we need to do differently
to achieve this. The Maternity Service Liaison Committee will be a key stakeholder
reference group prior to havingthe wider conversation with service users and public.
As the SuRNICC model is implemented over the next 18 months, bi-monthly updates
in the form of a Newsletter will continue, which will include the relevant elements of
maternity care. The Family Support workstream has recently been strengthened and
will be looking at what support women and families need. More information on the
SuRNICC development can be found http://howis.wales.nhs.uk/sitesplus/861/page/62447
Through the work on the Children’s Strategy and Care Closer to Home we will also
take the opportunity to work with partners in Primary Care, Social Services and the
third sector in developing a whole systems strategy. This work will include the
requirements of the Well-being of Future Generations (Wales) Act 2015 in improving
the social, economic, environmental and cultural well-being of Wales.
43
16.209.2 Appendix 3
8. NEXT STEPS
The principles and components of service identified within sections 6 and 7 of this
paper will now be developed further into a detailed plan to deliver this proposed
model of care, through engagement with staff, the public, women who use our
services and other stakeholders.
These plans will be reflected in the Board’s broader strategy, Living Healthier,
Staying Well, spanning health improvement, care closer to home, acute care and
childrens services.
44
16.209.2 Appendix 3
Appendix 1
EVIDENCE, STANDARDS & REVIEWS
Maternity Services
A vision for Maternity All Wales Maternity Strategy 2011
All Wales Perinatal Survey – Annual Report 2015
Adverse Childhood Experiences – 2016
Birth Rate Plus
Birthplace Study – Evidence update – PHW – May 2014
Guidelines for Obstetric Anaesthetic Services OAA and AAGBI - 2013
Healthy Child Wales Programme - 2016
Intrapartum Care: care of healthy women and their babies during childbirth – NICE
Guidelines 2014
King’s Fund – User Feedback in Maternity Services
Maternity Network 1000 Lives+
Measuring the health and well-being of a nation – Public Health Outcomes Framework
for Wales – March 2016
MBRRACE – UK – Mothers and Babies; Reducing Risk through Audits and
Confidential Enquiries (January to December 2014 – Published May 2016)
NCT – Championing Perinatal Peer Support - 2016
North Wales Implementation Plan 2016 – Maternity Strategy
Perinatal Guidelines / Pathway – BCUHB & NICE
Public Health Wales Literature reviews 2011 (Maternity & Neonatal)
Public Health Wales Population Profile - 2016
RCOG – ‘Saving Babies Lives Care Bundle’ 2016
RCOG – Options appraisal of Maternity Services at Betsi Cadwaladr University Health
Board, Wales - 2015
RCOG - Reconfiguration of women’s services in the UK – Good Practice No. 15 –
December 2013
RCOG Expert Advisory Group Report – High Quality Women’s Health Care: A
proposal for Change – 2011
Safer Childbirth – Minimum Standards for the Organisation and Delivery of Care in
Labour (RCPCH, RCA, RCOG, RCM) – 2007
Temporary Changes to Maternity Services in North Wales Consultation and Board
Report – 2015
The Birthplace cohort study: key findings 2011
Neonatal
All Wales Neonatal Standards 2nd Edition 2013 (3rd Edition in Draft)
BAPM Standards 2011
Bill Baby Charter and Audit Tool – 2012
First Ministers Advisory Panel – Siting of the Proposed Sub Regional Neonatal
Intensive Care Centre in North Wales. Strategic Outline Case – March 2014
RCPCH – Invited Review of the Options for Provision of Neonatal Care in North Wales
– September 2013
SuRNICC Full Business Case - 2016
SuRNICC Outline Business Case – 2015
Toolkit for High Quality Neonatal Services – DH 2009
45
16.209.2 Appendix 3
Appendix 2
GLOSSARY
Adverse Childhood
Experience
Ante Natal
Bronchopulmonary
dysplasia (BPD)
Cardiotocography
(CTG)
Central Lineassociated
Bloodstream Infections
ACEs are stressful experiences occurring during childhood that
directly harm a child or affect the environment in which they live,
and their association with health-harming behaviours in the Welsh
adult population
Care given to a pregnant woman before the birth of her baby
A chronic lung disorder of infants and children, it is more common
in infants with low birth weight and those who receive prolonged
mechanical ventilation to treat respiratory distress syndrome
Is used to monitor the babies heart beat and contractions
A Central Line (also known as a central venous catheter) is a
catheter (tube) that doctors often place in a large vein in the neck,
chest, or groin to give medication or fluids or to collect blood for
medical tests. A central line-associated bloodstream infection
(CLABSI) is a serious infection that occurs when germs (usually
bacteria or viruses) enter the bloodstream through the central line
Cerebrospinal fluid
A test to look for bacteria, fungi, and viruses in the fluid that
(CSF) culture
moves in the space around the spinal cord. CSF protects the
brain and spinal cord from injury
Ceasarean section / C- A Caesarean section is when a bay is delivered using a surgical
section
operation to cut through the mother’s abdomen and uterus
Midwife who provides care outside the hospital for example in a
Community Midwife
local clinic, GP practice or in the home
1 Consultant Midwife to 900 low risk women to support normality,
Consultant Midwife
reduce medical intervention and caesarean section rates
Delivery Suite (Labour Part of the hospital where both doctors and midwives are
Ward)
available to help women give birth
This is the term used for an anaesthetic given into the lower back
Epidural
area of the spine to reduce pain during childbirth
Equality impact
is a process designed to ensure that a policy, project or scheme
assessment (EqIA)
does not discriminate against any disadvantaged or vulnerable
people
Free Standing Midwife A place where women can give birth which is run by midwives at
Led Unit or Centre
a distance from the main obstetric unit. Usually only women at a
low risk of complications can give birth in a FMLU
Gynaecology
Treatment for women’s diseases and conditions
Is defined as "a combination of procedures, methods, and tools
Health impact
by which a policy, program, or project may be judged as to its
assessment (HIA)
potential effects on the health of a population, and the distribution
of those effects within the population."
Defined as the transfer of a mother to another hospital for
In-utero transfers
maternal care or predicted neonatal care for her newborn(s).
Local Supervising
Protecting the public through the statutory supervision of
Authority
Midwives
Maternity Services
Care for pregnant women until shortly after their baby is born
Midwife
The health professional who is an expert in normal pregnancy
and birth
46
16.209.2 Appendix 3
Midwife Led Care
Midwife Led Unit or
Alongside Midwife Led
Unit
Normal Birth
Neonatologist
Neonatal Care
The Nursing &
Midwifery Council
Obstetric Unit
Obstetrician
Paediatrics
Maternity care where the main health professional women seen
throughout the pregnancy and labour are all midwives. Women at
low risk of complications do not usually need to have maternity
care from a doctor unless a problem arises
A birth centre which is on the same site as the consultant
obstetric unit. This offers midwife led care for women at a low risk
of complications
A birth defined specifically as one where labour starts on its own,
the woman does not have an anaesthetic such as an epidural and
gives birth without intervention eg. Forceps or caesarean section
A doctor who specialises in looking after newborn babies who
need medical
Neonatal care means care given to newborn babies, usually for
up to the first 28 days of a baby’s life
Is the professional regulatory body for nurses and midwives in the
UK who’s role is to protect patients and the public through
efficient and effective regulation
Consultant led maternity unit, all types of births eg. Forceps,
caesarean sections and epidurals
Consultant doctors (senior) who specialise in pregnancy and birth
1. is the branch of medicine that deals with the medical care of infants,
children, and adolescents, and the age limit usually ranges from birth up
to 18 years of age
Perinatal
Pre-Term
Post Natal
2. Relating to the time, usually a number of weeks, immediately
before and after birth
3. Born before 37 weeks of pregnancy
Care given to a mother after her baby is born
Retinopathy of
Prematurity Screening
(ROP)
is one of the few causes of childhood visual disability which is
largely preventable
Sonography
A diagnostic imaging technique based on the application of
ultrasound. It is used to see internal body structures such as
tendons, muscles, joints, vessels and internal organs
Tertiary medicine
Tertiary care is specialized consultative health care, usually for
inpatients and on referral from a primary or secondary health
professional, in a facility that has personnel and facilities for
advanced medical investigation and treatment, such as a tertiary
referral hospital
47
16.209.2 Appendix 3
Appendix 3
ACRONYMS
ANNP
ACEs
APH
BAPM
BLISS
BMI
BCU/BCUHB
CTG
CMNNTS
EQIA
FMLU
FBC
HIA
HD
IC
LBW
LNU
LSA
MLU
MBRRACE UK
NNAP
NMC
NICE
NICU
OBC
RCOG
RCPCH
SC
SCBU/SCU
StC
SuRNICC
VLBW
WAST
WG
WMH
YG
YGC
Advanced Neonatal Nurse Practitioners
Adverse Childhood Experiences
Arrow Park Hospital
British Association of Perinatal Medicine
Bliss Registered Charity for babies born too soon. too small, too sick
Body Mass Index
Betsi Cadwaladr University Health Board
Cardiotocography
Cheshire and Merseyside Neonatal Network Transport Service
Equality Impact Assessment
Free Standing Midwife Led Unit
Full Business Case
Health Impact Assessment
High Dependency
Intensive Care
Low Birth Weight
Local Neonatal Unit
Local Supervising Authority (Midwives)
Midwife Led Unit
‘Mothers and Babies: Reducing Risk through Audits and Confidential
Enquires’
National Neonatal Audit Programme
Nursing Midwifery Council
National Institute for Clinical Effectiveness
Neonatal Intensive Care Unit
Outline Business Case
Royal College of Obstetricians & Gynaecologists
Royal College of Paediatricians and Child Health
Special Care
Special Care Baby Unit
Stabilisation Cot
Sub-Regional Neonatal Intensive Care Centre
Very Low Birth Weight (less then 1500g)
Welsh Ambulance Service Trust
Welsh Government
Wrexham Maelor Hospital
Ysbyty Gwynedd
Glan Clwyd Hospital