On one of my final visits as President of the RCM, I was keen to visit part of the UK I'd not yet seen. With the new Director of the RCM in Scotland, I visited the most northerly islands of Shetland and Orkney. The visit opened my eyes to huge opportunities as well as challenges presented by providing high-quality maternity services in remote, rural settings.
NHS Shetland and NHS Orkney are two of the smallest health boards of the 14 health boards in Scotland. The 13 midwives in Shetland provide care for around 200 women — assisted by a team of three specialist GPs. About 140 women give birth on the main island in the Gilbert Bain hospital's maternity unit and the remainder generally give birth across the water in Aberdeen. In Orkney, 11 midwives provide care for a similar number of women and births, supported by three obstetricians, with 50-60 women giving birth in the Aberdeen obstetric unit each year.
It was fascinating to see how maternity services have evolved to respond to the needs of the women in these remote communities and their dramatic landscapes.
In the Shetland Islands, midwives provide care across a continuum of women's lives, echoing the longitudinal care we have sometimes seen provided abroad. The midwives have each developed areas of special interest in which they have undertaken further study and gained experience. These include the provision of reproductive health care such as fertility services, sexual health services, early pregnancy assessment including ultrasound, and postnatal contraceptive services. The midwives work across both community and the hospital setting, providing antenatal and postnatal care to a caseload of women based geographically. Maternity support workers are an integral part of the team, supporting women with high BMIs during pregnancy with healthy lifestyle advice, providing smoking cessation support and setting up a baby massage group.
The service already reflected many recommendations of Scotland's recently published ‘Best Start’ review of maternity and neonatal services. The Best Start report advises women to receive the majority of their care as close to home as possible in ‘community hubs’ to develop a relationship with their key care provider, who will generally be a ‘primary midwife’ providing continuity of carer.
The report emphasises the need for specialist resources to be provided in centralised maternity and neonatal services, with efficient referral, transport support and strong multidisciplinary working. The review recognises that services in isolated settings will be quite different in their organisation from urban services.
Midwives in the Shetland Islands work closely with three specialist GPs. Specialist antenatal care is provided using telemedicine approaches to reduce the number of visits that women have to make to the mainland services in Aberdeen.
The Shetland and Orkney teams recognise the need to develop the level of continuity of carer through the intrapartum period to match the aspirations of the Best Start review for the primary midwife to provide care across the antenatal, intrapartum and postnatal continuum.
Geography and climate are the chief challenges for the maternity services in the Shetland Isles — some women live on islands miles from what the locals call ’Shetland mainland’ — as well as strong winds and difficulties recruiting midwives to work there. We met midwives who have worked on Shetland for their entire careers and others who moved from other parts of the UK. Their most recently recruited midwife moved to Shetland with her young family a year ago from Yorkshire. She felt that the islands enabled her to ‘be the kind of midwife she wants to be’, providing holistic care to women she really gets to know. Drawn by the island lifestyle, she has embraced her new way of life.
On the Orkney islands midwives work with many of the same challenges. During our time there we often heard about the ‘fragility’ of staffing and service models in these remote areas. There is a need to develop sustainable communities with health service models that support them. This requires midwives to be innovative and adaptable in how they approach their work. It is challenging for rural staff to maintain confidence and skills in more unusual and emergency situations. It requires strong systems to enable them to update and access continuing professional development regularly.
We were deeply impressed by what we witnessed in Shetland and Orkney. We can now take our new understanding of remote and rural maternity care, its challenges and its opportunities, to inform our ongoing work with the Royal College of Midwives and beyond.