Streamlining the multiple pregnancy pathway (Green maternity challenge)

Project completed as part of the National Green Maternity Challenge 2024-25 by the team at West Suffolk NHS Foundation Trust.

Team members:

• Georgina Clark, Obstetrics & Gynaecology Registrar, West Suffolk Hospital.
• Kate Croissant, Clinical Director of Obstetrics & Gynaecology, West Suffolk Hospital

Setting / patient group: Maternity (obstetrics)

Issue:

In the UK, 1 in 65 pregnancies results in a multiple birth. These pregnancies need extra monitoring, which means more appointments and investigations. However, inefficiencies in care pathways can lead to unnecessary duplication and inconsistencies in care. The area that West Suffolk Hospital serves means women often travel a long way for appointments and, combined with dissatisfaction with long waiting times, this can mean women do not attend. To improve sustainability and patient experience, a project explored streamlining appointments in the antenatal care pathway for multiple pregnancies, specifically dichorionic diamniotic (DCDA) twins, and making use of virtual alternatives where appropriate. A second focus was on improving the consistency and timing of information given to patients.

Intervention:

A retrospective audit was undertaken, comparing current practice (September 2023 to August 2024) with the recommended antenatal care pathway for DCDA twins. It highlighted that only one-third of pregnancies in that period adhered to the recommended schedule. Where patients were booked for appointments at both the antenatal clinic and community midwifery at the same gestation, they were more likely to attend those in the community. Of appointments suitable for telephone/virtual contact, only 8% were completed in this way. We involved stakeholders, including the core team for multiple pregnancies, obstetric registrars, community midwifery team and current patients. We mapped the current pathway and then designed a new antenatal schedule of care for DCDA pregnancies. For example, clinic appointments at 16 and 24 weeks were changed to telephone appointments (blood pressure and urine monitoring are undertaken during community midwifery appointments at the same gestation). The 28-week community midwifery appointment was removed (women attend antenatal clinic for ultrasound). We also digitised our printed proformas and patient information.

Outcomes:

Environmental

The carbon footprint for an outpatient consultation was calculated using several measures. Patient travel used an average round-trip distance of 48.9km, calculated using audit data and patient postcodes. The combined environmental cost for one outpatient face-to-face appointment was calculated as 16.06 kgCO2e. Using the environmental cost of one telephone appointment as 0.1kgCO2e, the total environmental cost saving across a single patient pathway was 47.98 kgCO2e. This is an average saving of 575.76 kgCO2e over the course of a year, equivalent to 1,696 miles (2,730km) of driving by car.

Social

Virtual appointments have many wider benefits to patients and their families, including less time off work, as well as a reduction in travel and therefore traffic on the roads. Additionally, the convenience of virtual appointments may allow increased involvement of the patient’s wider support network, resulting in a more holistic approach to maternity care, as well as a reduction in lost productivity resulting from their additional absence from work. By optimising antenatal appointment schedules and coordinating care closer to home for women where possible, this care pathway supports a holistic approach to maternity care for the woman and her family. There should be a reduction in waiting times and total time spent at antenatal clinic. There will also be a reduction in travel and parking costs for patients. We would also expect a positive impact on staff confidence and wellbeing, with a more efficient running of our antenatal clinics.

Clinical

With the small number of DCDA twin pregnancies at West Suffolk (12 per year) and the time period of the project (4 months), patient outcomes are difficult to determine, but we expect the standard of care to at least be maintained, if not improved. Our new schedule of care has been updated to align with the 2024 NICE guidance and we anticipate that care will become more collaborative, efficient and patient centred. Per patient, the changes mean one appointment fewer overall (from 12 to 11), and two virtual appointments in place of two face-to-face appointments. We will continue to audit implementation and expect to see an increase in the number of appointments conducted in adherence to the recommended schedule, a reduction in ‘duplicate’ appointments (clinic and community at same gestation), a reduction in missed appointments and waiting times, and we hope to see an increase in patient satisfaction.

Financial

The changes suggested are primarily designed to improve patient care but have the additional benefit of being service productivity improvements, with a financial saving. Using the NHS Payment Scheme workbook, we calculated that our changes could lead to a cost saving of £152.55 per patient, or £1830.60 per year across the service.

Additionally, as virtual appointments mean a reduced time commitment, there is a wider impact on the economy. Using a method described by the Strategy Unit and UK Government measures of productivity, changing a single appointment from in-person to virtual creates a lost productivity saving of £66.93 to the wider UK economy. Using a female employment rate of 72.1%, we have calculated the potential yearly lost productivity saving from our changes to be £1891.24.

Key learning point:

A key learning point from this project has been the need to maintain a flexible and iterative approach – with the benefits of testing small changes, gathering feedback and refining implementation being key. Ongoing data collection will be crucial to assessing the long-term impact and effectiveness of these changes, so that we can refine this model before considering its expansion to other appropriate antenatal pathways, such as gestational diabetes.