Nottingham Insight

Pregnancy (2016)

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Topic title Pregnancy
Topic owner Lynne McNiven
Topic author(s) Sarah Diggle, Helena Cripps, Uzmah Bhatti
Topic quality reviewed 23rd September 2015
Topic endorsed by Maternity Pathway Development Group
Topic approved by Maternity Pathway Development Group
Current version September 2015
Replaces version 2010
Linked JSNA topics

Executive summary

Introduction

What happens during the early years, starting in the womb, has lifelong effects on a range of health and wellbeing outcomes including obesity, heart disease, mental health, educational attainment and economic status[i]. Healthy mothers are more likely to have healthy babies and a mother who receives high quality maternity care throughout pregnancy is well placed to provide the best possible start for her baby. It is therefore not an overstatement to say that the future health of the nation depends on maternal health.

Pregnancy is a particularly important period during which the physical and mental wellbeing of the mother can have lifelong impacts on the child. For example, during pregnancy, factors such as maternal stress, smoking, diet and alcohol or drug misuse can place a child’s future development at risk. A wide range of research now shows that conception to age 2 is a crucial phase of human development and is the time when focused attention can reap great dividends for society[ii].

Improvements in socio-economic conditions and obstetric care have made significant contributions to reducing maternal and infant mortality such that good outcomes from pregnancy have become the expectation and the norm. However, not all groups have the same outcomes and there remains a gap nationally between routine and manual groups and the England average in key outcomes such as infant mortality. If we are to improve outcomes further we need to address social and environmental factors, improve care to those most at risk of poorer outcomes and to take advantage of technological advances.

Unmet service needs and gaps

  • There has been no reduction in indirect causes of maternal mortality for 10 years; the rise in maternal obesity, the high smoking prevalence and the rise in the proportion of women with medically complex pregnancies makes this a key concern for Nottingham.
  • The percentage of Nottingham’s pregnant women accessing maternity services early in pregnancy appears to have reduced and is lower than national targets. This increases risks of poor maternal and infant outcomes.
  • Nationally, pregnant women with complex social factors are much less likely to access maternity services early in pregnancy and data suggests this is mirrored in Nottingham.  Early access amongst these groups during 2014/15 ranged from 10% to 83% (all below the 90% target).
  • Pregnant women who are recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English are the least likely to access Maternity services within recommended timescales.
  • Almost one third of Nottingham’s births are to mothers born outside the UK. 280 (6%) mothers had difficulty reading or speaking English; these women and their babies are at increased risk of poor pregnancy outcomes.
  • There is an increasing need for translation services during pregnancy and challenges in gaining timely access to these services, particularly in emergency situations.
  • The Serious Crime Act 2015, places a new duty on professionals to notify the police of FGM. This will require awareness raising and training of all professionals in contact with pregnant women.
  • During 2013, the age group with the highest number of abortions was the 20-24 year group.
  • Although data on domestic abuse is collected by maternity services, it has not been possible to extract this data; therefore there is a lack of understanding about how many pregnant women are experiencing domestic abuse. However, data on domestic abuse in the general population suggests that this is likely to be a significant concern.
  • It is not currently routine practice for midwifery to have a dedicated appointment alone with the pregnant women to ensure that opportunities for disclosure of domestic abuse are optimised.
  • Maternal mental health is a significant issue in Nottingham with 864 (18%) pregnant women reported to have mental health issues during 2014/15.
  • The perinatal mental health pathway may not be meeting the needs of pregnant women with low level mental health needs.There is a potential gap in the identification and referral of women with low level anxiety and depression to services through Early Help Services.
  • Smoking in pregnancy poses significant risks to maternal and infant health and is significantly higher in the City than the England average and the gap is widening.
  • It is unknown which groups of pregnant smokers are least likely to access smoking cessation services and/or successfully quit.
  • There is a need to increase referrals to smoking cessation services from acute midwifery service, health visiting, Family Nurse Partnership, Early Help services and other Early Years providers to support cessation of smoking in pregnancy and prevent high levels of post-natal relapse.
  • A targeted approach of reducing smoking prevalence in pregnancy among teenage and young mothers is required.
  • The prevalence of obesity is a key issue for maternal and infant health in Nottingham.
  • It is estimated that more than a quarter of Nottingham women of child bearing age are binge drinkers. Given that half of pregnancies in the UK are unplanned, this potentially poses significant risks to infant outcomes.
  • The uptake of flu vaccination in pregnancy is significantly lower in Nottingham than the England average (34%).
  • There is a need to significantly increase the proportion of pregnant women who receive a 28-week antenatal visit from the health visiting service.
  • There is uncoordinated provision of universal antenatal education by midwifery and health visiting services and Early Help Services are not involved in delivery.
  • The reach and coverage of ‘Preparation for Birth and Beyond’ antenatal education provided by health visiting is unknown (i.e. numbers (%) accessing and who is/isn’t accessing). In addition, the programme is not currently multiagency provision.
  • There are no specific programmes or interventions provided by Nottingham City Council Early Help Services for pregnant women, yet there is great potential for reaching and supporting pregnant women, especially those with complex social factors.
  • Information technology requires improvement across the maternity pathway.  The maternity system used in the acute setting, Medway, should be implemented in the community to enable maternity records to be accessed and updated by midwives based in the community whilst ensuring safe and effective data sharing with other services including GPs and health visiting services.

Recommendations for consideration by commissioners

  1. Develop and widely promote direct access to midwives.
  2. Conduct a Health Equity Audit of early access to maternity services and develop strategies for increasing early access among groups of women identified as least likely to access early, in particular recent migrants, refugees, asylum seekers and those who have difficulty speaking or reading English.
  3. Ensure adequate provision of translation services during pregnancy and birth. Multilingual leaflets and materials should be standard practice.
  4. Face to face interpreting services should be encouraged and telephone interpreting as a minimum used at each appointment when required. Family members, legal guardians or partners should not be used as an interpreter in the antenatal or postnatal period unless in an emergency
  5. Improve continuity of care for women by named midwife.
  6. Increase opportunities for women with low risk pregnancies to receive midwifery led care at delivery and home births.
  7. Further develop specialist midwifery support to incorporate all complex social needs and ensure a more equitable service.
  8. Improve information technology to ensure electronic records are accessible across the maternity pathway.
  9. Commissioners and providers of early years services should continue to work together to ensure effective and timely information sharing across organisational boundaries.
  10. Explore the opportunity for Nottingham City Council (NCC) Early Help Services to contribute to positive maternal health (every contact counts).
  11. Complete the Smoking in Pregnancy Assessment Tool (based on the CLeaR model) which aims to help areas to reduce smoking rates in pregnancy using a whole systems approach.
  12. Develop and implement a smoking in pregnancy multi agency pathway (Midwifery, HV, FNP, Early Help Service, Early Years providers) which extends into the postnatal period.
  13. Continue to implement routine Carbon Monoxide (CO) testing at pregnancy clinics to help identify women who smoke during pregnancy.
  14. Specific interventions to reduce smoking in pregnancy and support women who want to quit smoking in pregnancy should be enhanced and based on latest evidence in the Healthy Child Programme Rapid Review.
  15. Midwives who deliver intensive stop-smoking interventions (one-to-one or group support) should be trained to the same level as specialist NHS Stop Smoking advisers (and receive ongoing support).
  16. Prioritise pregnant women in the development of the new Healthy Lifestyle Programme across the City.
  17. Explore the barriers to flu vaccination uptake in pregnant women and promote widely through midwifery, health visiting and other early help and early years providers.
  18. Review current provision of antenatal classes and develop a coordinated multi-agency (midwifery, health visiting and Early Help services) provision of Preparation for Birth and Beyond. 
  19. Conduct a health equity audit to identify equity of access to Preparation for Birth and Beyond.
  20. Ensure Preparation for Birth and Beyond is accessible and attractive to expectant parents in higher-risk groups (e.g. teenage mothers and fathers) and in minority groups. Consider men only sessions within the programme targeted specifically at adolescent fathers.
  21. Strengthen the maternal mental health pathway to support women with emerging mental health needs to access appropriate support.
  22. The perinatal mental health pathway should ensure that women with anxiety disorders in pregnancy or the postnatal period should be offered a low-intensity psychological intervention (i.e. facilitated self-help) or a high-intensity psychological intervention (i.e. CBT) as initial treatment in line with the recommendations set out in the NICE guideline for the specific mental health problem.
  23. At the first contact with primary care or at pregnancy booking visit, and all contacts after, the HV and other health care provider who have regular contact with a women in pregnancy and the postnatal period (one year after) should consider asking the two Whooley depression identification questions and the GAD- 2 as part of a general discussion about her mental health using the EPDS or the PHQ- 9 as part of monitoring.
  24. Prioritise the promotion of mental health and wellbeing through the Early Help service as outlined within Nottingham City's mental health strategy-Wellness in Mind.
  25. Explore the possibility of incorporating couples counselling into current IAPT services.
  26. Audit the perinatal mental health pathway to assess effectiveness of the interventions.
  27. Promote multi-agency commitment to 'making every contact counts' around lifestyle issues (smoking, healthy weight, alcohol, safe sleeping, mental health and wellbeing, parenting and attachment etc.).
  28. In partnership, develop a clear consistent message to pregnant women on alcohol usage in pregnancy based on the Chief Medical Officer guidance and local consultation and ascertain alcohol usage in pregnancy through the Audit C tool.
  29. Ensure the co-ordination of Healthy Start/Vitamin D is incorporated into the Health Visiting Specification and continue provision of free vitamins for all pregnant women.
  30. Evaluate the effectiveness of the Maternal Obesity Programme (Bumps and Beyond) including equity of access.
  31. Develop a local FGM pathway based on the Department of Health FGM pathway to ensure identification/assessment and appropriate referral.
  32. Prioritise mandatory training on FGM in service specifications to ensure awareness and effective referral processes.
  33. Continue to support a reduction in teenage pregnancy rates and explore ways to increase the coverage of FNP.
  34. Ensure all health and social care professionals are trained in how to respond to domestic abuse in a way that makes it easier for people to disclose it.
  35. The opportunity to be seen alone during pregnancy should be routine practice by midwifery in order to appropriately discuss domestic abuse.
  36. 36. Embed the Pocket Midwife and Baby Buddy apps across all pregnancy and early years services to enhance communications with expectant and new mothers and ‘make every contact’ count.

[i] The Marmot Review (2010) Fair Society, Healthy Lives London: The Marmot Review. Available at: http://www. instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review. [Accessed 18.09.15]

[ii] Wave Trust (2013). Conception to age 2– the age of opportunity. Addendum to the Government’s vision for the Foundation Years: ‘Supporting Families in the Foundation Years’. Available at: http://www.wavetrust.org/sites/default/files/reports/conception-to-age-2-full-report_0.pdf. [Accessed 18.09.15]

 

Key contacts

Lynne McNiven, Consultant in Public Health, Nottingham City Council Lynne.McNiven@nottinghamcity.gov.uk

Sarah Diggle, Insight Specialist Public Health, Nottingham City Council. Sarah.diggle@nottinghamcity.gov.uk

Alicia Rowley, Commissioning Manager (Children and Families), Nottingham City CCG alicia.rowley@nottinghamcity.nhs.uk

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