Seòmar agus comataidhean

Thank you. I apologise—Sue Webber’s sound was a little glitchy at my end.

The first thing to say is that the Scottish Government recognises the impact of baby loss. It is absolutely clear that women who experience baby loss need the right information and care and support that take into account their personal circumstances. The loss of a baby at any stage of pregnancy is an absolute tragedy that has a profound effect on families, including on their mental and physical health.

The Scottish Government recognises that; we are very clear that women and their families need the right care and support. A lot of work is going on across the country to ensure that women and their families are provided with tailored care, including through following of guidance from the National Institute for Health and Care Excellence and the Royal College of Obstetricians and Gynaecologists.

On consistency across the country, the committee will be aware that we have started to implement an incredible programme called best start, which encourages flexible family-centred and person-centred care that is suited to the needs of the individual. Best start will undoubtedly improve the situation.

Unfortunately, however, the pandemic has struck mid-implementation. Although some health boards were far advanced in their work on best start, others were in the early stages of implementing it. We are keen to pick up best start from next year and we expect to see a great deal of improvement and consistency of services when best start is applied across the country.

We have also been working with third sector organisations, including Sands—the stillbirth and neonatal death charity—to develop the national bereavement care pathway for bereavement or loss, which will provide health professionals with evidence-based care pathways and will describe best practice for bereavement care. We are working on rolling that out across the country.

As I have said, a great deal of work is going on across the country. Although the work has undoubtedly been impacted by the pandemic, I think that we are on the right path. Once we are able to implement best start fully, we will see progress on that front.

The pandemic shone a light on pre-existing health inequalities, and it exacerbated them. We have seen that in maternity care, too. Unfortunately, even in this day and age, the strongest predictor of the worst outcomes during pregnancy is a person’s level of wealth. People from areas where deprivation is high are more likely to have poorer outcomes. As Dr Gulhane says, we also see health inequalities along black and minority ethnic lines. Outcomes from maternity and pregnancy are often poorer for women from black and minority ethnic backgrounds.

It is a difficult issue to study because, in Scotland, numbers are relatively small and outcomes are generally good. Outcomes from pregnancy are largely good in Scotland, and the number of cases where things go wrong is quite small. It is therefore a challenging area to study. However, we work closely on the issue with our neighbours in the other UK nations. Kirstie Campbell can explain some of the work that is going on in England, from which we are benefiting, to look more closely at how we can meet the needs of black and minority ethnic populations during pregnancy.

The first thing that I want to do, if you will indulge me for a moment, is pick up on Sandesh Gulhane’s point that there has been low vaccination uptake among pregnant women from black and minority ethnic backgrounds. This is an opportunity for me to emphasise just how important vaccination against Covid-19 is during pregnancy. It is perfectly understandable that there was hesitancy and concern in accepting a new product when it first came on the market over a year ago, but vaccinations against Covid-19 have now been used worldwide in millions and millions of pregnant women. The evidence is now solid that the benefits outweigh the risk.

We need to increase vaccination in pregnant women because they appear to be more susceptible, particularly to delta, than the rest of the population. One way in which we are approaching that is by holding specialist vaccination clinics in maternity services. For example, NHS Greater Glasgow and Clyde has been holding vaccination clinics for pregnant women and, because of the catchment areas, those clinics naturally target black and minority ethnic communities.

I could not let the opportunity pass to emphasise just how important it is for our pregnant women to get vaccinated and to be fully vaccinated during pregnancy. They have every opportunity to talk to health professionals and the vaccinator if they have any concerns at all. The evidence is very solidly behind vaccination during pregnancy now.

On your broader question, convener, I will simply start at the beginning. At the start of the pandemic in March 2020, every service in the national health service pivoted to a digital response. Face-to-face visiting was reduced. Those were the days before we had a vaccine, and things were very dangerous. We managed to get through the early pandemic largely by pausing almost anything and everything.

However, family nurses and health visitors worked very closely with local partners in designing perinatal and infant mental health pathways to make sure that the community could continue to be looked after. In recognition of the importance of support for new parents and babies at a time of national emergency, very few of those individuals were redeployed. If you think back to March 2020, people were being redeployed, for example, from paediatrics to Covid wards, but our health visitors and our family nurses largely were not. We know how important it is to support women and families at these times.

The importance of prioritising visits for new babies was emphasised, and the guidance was adapted throughout the pandemic. Where possible, there was an emphasis on returning to face-to-face visiting, but that has not been possible at every stage of the pandemic. We have seen an amazing adoption of digital options, such as NHS Near Me for antenatal checks, blood pressure monitoring and things like that. Support was continued, but it was not always continued face to face.

We have always recognised the importance of having partners there at significant appointments during the antenatal period, at the birth and postnatally. We have always tried to enable that to happen. There have been challenges in individual maternity units with insufficient space for social distancing in the room. We had to leave flexibility for health boards where the risk assessment was that extra people could not be in the room. However, throughout the pandemic, we have recognised just how important it is for women and their partners to go through those experiences together and to be able to support each other at antenatal appointments, during the birth and in the postnatal period.

That is a really important point. I will bring in Carolyn Wilson to provide some more evidence on that, but first I will give you my initial thoughts.

The issue is important. For a long time, since before the pandemic, far too many women have given up breastfeeding not because they wanted to or chose to, but because they were not given support in the early days. We have been working on the issue for a very long time. I hear what the convener says about some women feeling that they were not supported well.

However, the reality is that, during the pandemic, breastfeeding rates went up. It is complex to unpick that; we are still trying hard to understand why that was the case. The most recent infant feeding statistics show that almost two thirds of babies who were born in the 2020-21 financial year were breastfed for at least some time after their birth. That figure is up 1 per cent on the previous year. More than half of those babies were being breastfed when their health visitor first visited, which is between 10 and 14 days after the birth, and 38 per cent were being exclusively breastfed. Those figures show increases of 2 per cent and 1 per cent, respectively, on the previous year.

The proportion of babies aged six to eight weeks who are being breastfed is at its highest since records began. Many people would say that it is still too low, but the figure is up to 45 per cent, and 32 per cent of babies are being exclusively breastfed, which is an increase of 1 per cent on the previous year.

Although I would not dream of dismissing the women’s experiences that the convener mentioned, the data show that we have, at population level, managed to get something right in relation to breastfeeding support during the pandemic. I am not sure whether that was because fathers were often at home or because more support was provided virtually in people’s homes, so people did not have to go out to ask for help. We will unpick the details.

All the improvements have come against the background of a commitment to breastfeeding in Scotland over decades. Carolyn Wilson might be able to set the scene better than I can, but Scotland was the first UK nation to achieve 100 per cent accreditation from the UNICEF UK baby friendly initiative, which was an important landmark in improving breastfeeding rates. The committee will be aware that there are massive cultural factors that influence whether women and families choose to breastfeed and whether they are able to and supported to do so. The UNICEF UK baby friendly initiative gave us strong evidence-based practice with which to improve breastfeeding rates in Scotland.

You are absolutely right to highlight that baby loss impacts not just the mum but the father. I said clearly that we talk about family-centred care, so I include the father and, in fact, the entire extended family.

You will be aware that, before I came into politics, I was an antenatal teacher. I talked a lot about how babies are sometimes born in a medical event, but they are always born in a social event—they are always born into a community and family, and the whole family and community need support when things go wrong.

You are right that pregnancy is an uncertain time and that sometimes things do not go as expected. Since 2017, we have provided more than £16 million in funding to support the implementation of “The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland”, which we think is the solution to many of the challenges and traumas that people face during pregnancy. That five-year plan was published in 2017 and, as I said, it remains a firm programme for government commitment. Person-centred high-quality care for mums and babies throughout pregnancy and birth, and following birth, can have a marked effect on the life chances of women and babies and families, and on the healthy development of the child throughout their life.

We are aiming for gold-standard care. We want truly family-centred care that will maximise the opportunities to establish building blocks for strong family relationships and for confident and capable parenting. One cornerstone of that type of care is the continuity of carer. There has been a lot of discussion on that with regard to baby loss. Continuity of carer has a significant impact on, and makes a difference to, the experience of people and families who have lost a baby.

We are continuing to introduce continuity of carer in maternity services. That is the care that midwives have told us they want to deliver—the type of care that they want to be involved in—but it is also the care that women have told us they want to receive. They want to build a relationship with a midwife, not just through their pregnancy, birth and beyond, but in subsequent pregnancies. Where there has been loss or trauma in one pregnancy, continuity of carer becomes absolutely vital in subsequent pregnancies.

The best start approach equips midwives with the skills to care for women with socially complex needs and their babies. The midwives have reduced case loads, and there is continuity of carer. There is additional training, and there are clear pathways of care and co-ordinated multi-agency support. The best start for any baby is that the mum receives continuity of carer from a primary midwife who is supported by a small team. That primary midwife is really important for women with additional complex needs, such as those with substance misuse issues.

As I said, work is under way to produce nationally consistent guidance and pathways and to cope with different levels of complexity. The midwife will always be the lead carer, but there might be a greater need to work closely with other services. Early access to care is important for building a high-quality antenatal relationship between the mum or family and the midwife. It is really important for mum and baby.

For women with a whole range of medical, social and psychological complexities, early intervention and co-ordinated multi-agency care make a massive difference to outcomes. That begins at the initial booking appointment, when the midwife first sees the mum during pregnancy. At that stage, women are asked a variety of questions about their wellbeing in order to assess the likelihood that they have additional needs.

My colleague Kevin Stewart might want to talk specifically about some of the perinatal mental health approaches that support women from the antenatal period right through to the postnatal period.

Kevin Stewart mentioned delivery of services being different in different parts of the country. Delivery of universal services has looked different during the pandemic, as well. Antenatal classes moved to online delivery and breastfeeding support groups have, largely, moved to closed Facebook groups and other social media.

Social media have provided virtual opportunities to connect not only mums who have babies but families, and to encourage outdoor meet-ups. Around the country, walk and talk groups have begun. That has happened out of necessity—because it is safer to meet outdoors than it is to meet indoors and small numbers are safer than large numbers. However, as a public health minister who is thinking about the general health of the population and the challenges that we have in getting people active and maintaining healthy weight—it is particularly important for women to be a healthy weight during pregnancy—I hope that that continues. The opportunity to meet up outdoors and walk together—to socialise through exercise—is probably a valuable step forward, but I look forward to the day when it is not the only option.

You have heard, throughout our evidence, about joined-up care and the holistic approach. Those concepts are a cornerstone of care in the perinatal period. We are taking specific actions to improve joined-up services for women and families with complex needs, including those in which there is substance use. We have talked about that and the best start approach.

Prior to the pandemic, we made a significant investment in increasing health visiting. We have increased the health visiting workforce by almost 50 per cent in order to build capacity and to provide more support to individuals who need it. That represents a significant difference between the approach in Scotland and the approach in the other UK nations. That is because we recognise the incredibly valuable role that our health visiting teams play for new families. We have invested in them and have supported them in their role.

I will bring in Kirstie Campbell to give you the most up-to-date picture of delivery across the country. Kirstie, can you give information on where we are at the moment and where we hope to be early next year? I am aware that we are again in uncertain times because of the pandemic.

It will come as no surprise to you to hear that I believe that universal services play a key role in the prevention and early detection of perinatal mental health problems, from pre-conception onwards. Public health messaging on awareness of mental health and positive health behaviours and relationships has a significant impact on subsequent emotional wellbeing.

All the members of the team—midwives, health visitors and family nurse practitioners—play a crucial role in identifying and preventing perinatal mental health problems. That is why we have invested in the NES perinatal and infant mental health curricular framework that we have discussed. It offers a suite of multidisciplinary training options to support universal and specialist staff to develop their knowledge and skills so that they can feel confident about addressing mental health and wellbeing issues with the women whom they work with. You might want to discuss it further with Kevin Stewart, but I believe that all mental health staff can also access those modules, especially those who work in relevant specialist areas.

With regard to universal services, perinatal mental health is a fundamental part of the core curriculum. We are trying hard to make sure that, regardless of where staff work or their specialty, perinatal mental health is an important part of their training and of their continuing professional development, as they go through their working lives.