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Topic on a Page - Maternal Health Pregnancy the First Few Weeks of Life

Data Sources:

Public Health England Child Health Profile

Further Data Sources:

Scroll to the bottom of the page to view and compare further datasets

Supporting Information:

NHS:

Better Births Strategy and Implementation Plan for Lincolnshire 2017 – 2020/21

King's Fund:

Maternity

National Institute for Care and Health Excellence (NICE):

Antenatal and postnatal mental health: clinical management and service guidance [CG192] Updated: April 2018

NICE Resources: Fertility, Pregnancy and Childbirth

NICE Pathway: Antenatal care for uncomplicated pregnancies overview

NICE Pathway: Intra Partum Care Overview

NICE Pathway: Postnatal Care Overview

NICE impact: Maternity

Antenatal Care for Uncomplicated Pregnancies [CG62] Updated February 2019

Hypertension in pregnancy: diagnosis and management [NG133] published June 2019

NHS England (NHSE):

Maternity Review Published: February 2016

Perinatal mental health care pathways

NHS Evidence:

Alcohol and Pregnancy

Antenatal Care

Caesarian Section

Diabetes and Pregnancy

Ectopic Pregnancy

Labour

Postnatal Depression

Smoking and Pregnancy

Public Health England (PHE):

Local action on health inequalities: Evidence papers Published: September 2014

Best start in life: cost-effective commissioning

Newborn and infant physical examination screening: standards

Supporting the public health nursing workforce: health visitors and school nurses delivering public health for children and young people (0-19): Guidance for employers

Updated Standards for infectious diseases in pregnancy

Health matters: reproductive health and pregnancy planning Published: June 2018

Guidance on screening checks and audits to improve quality and reduce risks

Linked Topics:

Topic last reviewed: June-19

JSNA Topic: Maternal Health, Pregnancy & First Few Weeks of Life

Background

The health of a baby is crucially affected by the health and well-being of its mother and by other family relationships. Pregnancy and the first few weeks of life can affect health, well-being and educational outcomes throughout the entire lifespan of an individual. Risks to mother and baby during pregnancy and the first few weeks of life can include communicable diseases, physical and mental health problems.

Women can experience the same mental health problems as the general population but these are particularly important to address during this period because of the effect they can have on the foetus, baby, family and mother’s health. Depression and anxiety are the most common mental health problems during pregnancy and post-partum and in the first year after birth (NICE guidance [CG192]). Problems are not always disclosed, recognised or treated during this period, making assessment by professionals at all contacts extremely important.

In babies and toddlers, healthy social and emotional development is important to prevent behavioural problems and mental illness later in life and support educational attainment.

Antenatal and maternity care is a continuum of need throughout a woman's reproductive years and can be an opportunity to identify and influence physical, behavioural, psychological and social risk factors for both mother and baby through offering services and support. For many families, pregnancy and new parenthood is a time to reflect upon lifestyle choices, and positive health behaviours may be more likely to be adopted during pregnancy (McBride et al, 2003).

Access to good quality care reduces the risk of challenging and adverse outcomes including pregnancy loss, perinatal death and infant mortality, maternal mortality, and low birth weight/ premature birth.

Context

National Strategies, Policies & Guidance

NICE: Pregnancy Pathway: this covers all NICE has produced on the topic of pregnancy and maternal health, including related guidelines, NICE Pathways, quality standards and advice. Topics include antenatal care, postnatal mental health, diabetes, diet, hypertension, labour, nutrition, postnatal care, and smoking as well as NICE advice on health visiting and 12 specific NICE guidance documents. These are available from: NICE: Pregnancy Pathways.

NICE: Social and emotional wellbeing: early years [PH40] This guidance aims to define how the social and emotional wellbeing of vulnerable children aged under 5 years can be supported through home visiting, childcare and early education. The term ‘vulnerable’ is used to describe children who are at risk of, or who are already experiencing, social and emotional problems and need additional support. This is available from: NICE: Guidance [PH40].

NICE: Quality Standard: Early years: promoting health and wellbeing in under 5s [QS128) This quality standard covers services to support the health, social and emotional wellbeing of children under 5. This includes: home visiting, childcare, early intervention services in children’s social care, and early education. The standard includes vulnerable children who may need additional support. This is available from: NICE: Quality Standard [QS128].

The Better Births report, which reviewed maternity services, emphasises the need for women and families to be supported in their choices around maternity care.

The Healthy Child Programme provides the basis for planning all children’s services from pregnancy to the first five years of life, based upon evidence of best practice.

Local Strategies & Plans

Local plans for maternity services are part of Lincolnshire's Sustainability and Transformation Plan.

A Lincolnshire maternity transformation plan has been developed, arising from the national Better Births report and strategy. This plan provides the framework for safe and improved local maternity and neonatal services that recognise and reflect the individual personal needs and choices of women and families in Lincolnshire.

The plan has been built on extensive engagement with women and their families, staff and others involved in the commissioning, provision and support of local maternity services to ensure an honest and accurate assessment of current services and co-produce the vision for what best practice would look like in Lincolnshire.

Details on the local transformation plan can be found on Better Births website for Lincolnshire.

What is the picture in Lincolnshire?

What the data is telling us

Child and Maternal Health indicators published by Public Health England can be viewed either by life-course stage or theme; topics include pregnancy and birth, early years, children’s and young people’s mental health and wellbeing, mortality and breastfeeding. Key headlines from the data are:

As described in the Annual Report of the Director of Public Health on the health of the people of Lincolnshire 2016, depression and anxiety are the most common mental health problems experienced during the perinatal period. As per the perinatal mental health profile, the estimated number of women with severe depressive illness, calculated by applying the national prevalence estimate (30 in 1,000) to the total number of maternities (including stillbirth deliveries) in Lincolnshire was 171 women in 2017/18. The estimated number of woman with PTSD in the perinatal period for the same time period was 171. In 2017/18 the estimated number of women with mild-moderate depressive illness and anxiety, ranged from 569 at the lower estimate up to 853 as the upper estimate in Lincolnshire. The estimated number of women with adjustment disorders and distress in the perinatal period was 853 at the lower estimate up to 1706 at the upper estimate. There are some concerns regarding the quality of the estimates around these indicators. Additional information regarding perinatal mental health can be found in the Perinatal Mental Health Catalogue.

Further guidance regarding child and maternal health data and intelligence can be found at Public Health England.

Trend

The number of live births in Lincolnshire has steadily decreased overall by 3.6% over the past 7 years. There has been no significant change in terms of the general fertility rate (GFR) (total number of live births per 1,000 women aged 15-44,) in Lincolnshire from 2010 (60.2 per 1,000 females) compared to 2016 (59.8 per 1,000 females). A steady decline is seen when looking at the total fertility rate which was 2.09 per 1,000 women of child bearing age in 2010 compared to 1.76 per 1,000 women of child bearing age in 2017. Population projections show further that the birth rates are likely to remain stable or fall slightly over the coming years. The number of live births to women below the age of 20 has fallen in Lincolnshire since 2015 by 1%, but has remained above national levels, whilst the number of live birth to mothers above the age of 40 have remained below national levels during same time period.

Premature births at 37 week gestation has remained similar or below national levels since 2006-08.

Since 2010 the proportion of full term babies born at low birth weight in Lincolnshire has fallen from 2.5% to 2.41% in 2017, remaining below the national and regional level since 2006. The proportion of very low birth babies in 2016 was significantly lower in Lincolnshire than national levels for the first time since before 2010. It is too early to say if this improvement represents a consistent change.

Both neonatal mortality and post-neonatal mortality have remained similar to national levels since 2012-14. Trends for infant mortality have also remained similar to national levels since 2010-12. Differences in mortality rates should be viewed over time and with caution due to the small numbers within the data.

In Lincolnshire the percentage of women who smoke at time of delivery has been significantly worse than national levels since 2010/11, whilst the overall trend indicates a decrease, despite the 3.4% increase in 2017/18. However due to data quality issues for this indicator the data should be viewed with caution.

Key Inequalities

Reducing the percentage of women who access maternity services later in pregnancy through targeted outreach work for vulnerable and socially excluded groups will help to reduce the health inequalities these groups face whilst also guaranteeing choice to all pregnant women.

The early years of a child's development lays down the foundation for the whole of their life. The Marmot Review refers to the strong links between a child's physical, social and cognitive development during the early years and their readiness for school, educational attainment, future economic participation and health. Development begins before birth when the health of the baby is affected by the health and wellbeing of the mother.

Low birth weight is closely linked to maternal smoking and smoking status correlates strongly with higher levels of deprivation. The most vulnerable groups in our society therefore, are most likely to have poorer health, reduced quality of life, poorer educational outcomes and an overall shorter life expectancy for many.

Infant mortality is closely associated with aspects of health inequalities, deprivation, housing quality and living environment, maternal lifestyle factors, infant feeding choices, and access to services. These in turn are potentially influenced by, amongst others, the education level of the mother, her age, and her income. Crucially, there is no single method of tackling these wide ranging associations.

Current Activity & Services

Community Hubs

Community hubs have been developed in Lincolnshire as part of NHS England’s Better Births Maternity Transformation Programme. There are now a total of 100 hubs across the country, eight of which are in Lincolnshire: the initial schemes starting in Lincoln, Grantham, Boston and Skegness. These sites were chosen as they are situated in some of the county's most deprived communities, have good footfall into the centre buildings and had strong developing links with midwifery and health visiting teams.

The plan focused on bringing new families together so that parents have care close to home, in the community from their midwife and from a range of other services - particularly for antenatal and postnatal care - and continue to engage with services in the Children Centres.

The aim of the original pilot was to engage with all eligible adults in these areas, whilst also focusing on referrals for people who fall within our target groups – including families working with Early Help or Social Care services; Eastern European families; families living in areas of deprivation; workless households; adults who smoke; as well as those who have addiction issues, have suffered domestic abuse or are obese.

Early results from the first year of inception have been positive, with attendance at Midwifery clinics and Health Visitors appointments within the centres supporting an increase in attendance at other groups. The benefits of having services all under one roof has been seen by families and professionals, and regular contact with the same group of people has supported the vision for 'continuity of care'.

Other Activity & Services

Advice on preparing well for pregnancy by stopping smoking, maintaining a healthy weight, diet and folic acid supplementation are available through GPs, pharmacies and sexual health clinics.

Early access to care (by 12 completed weeks of pregnancy) maximises the opportunity to support women and their partners during pregnancy and identify potential problems early through detailed health and social care assessment of needs, risks and choices.

Detailed information on maternity and new-born services (including self-referral) is available on the Better Births Lincolnshire website.

The 0-19 children’s health service offers health visiting and nurses for school aged children. Health visiting provides universal care to children and their family from the antenatal period until the child reaches the end of reception class (0-6years). This includes:

  • Antenatal education
  • Antenatal birth visits (6-8 week assessment, 8-12 months assessment and 2-2.5 year assessment)
  • Help with feeding your baby and growth and development
  • Parenting and child behaviour advice
  • Maternal mental health.

Geography and travel times in Lincolnshire greatly influence choices in care; particularly in choosing a location for the birth. Other choices, such as home births are also having an increasing influence.

All contacts with pregnant women include assessment of mental health in accordance with NICE clinical guidance [CG192]. Women have access to the same psychological therapies as the general population through self-referral, or via their GP or other health professional, in addition to specialist perinatal mental health services. The Perinatal Mental Health Services (PERIMNS) provides assessment, support and treatment for childbearing women with, or at risk of serious mental illness who cannot be managed effectively by primary care or other mental health services. PERIMNS also offer advice and assistance to other professionals on the treatment and management of serious perinatal mental illness. Additional targeted services such as 'Birth Afterthoughts' (Lincoln based) support women who have had a difficult or traumatic delivery, and a United Lincolnshire Hospitals Trust service that works with families in the event of a miscarriage/stillbirth or neo-natal death.

Lincolnshire benefits from a large network of children centres that support children and families. Early Help Workers deliver a range of evidenced based programmes addressing home conditions, budgeting or parenting to help the family prepare practically and emotionally for the birth, one to one at home or in a group. For pregnant teenagers there is a Young Expectant Parent (YEP) programme, supported by the use of virtual babies.

Stop smoking services focus on encouraging women to quit around the time of pregnancy and cessation advice is incorporated into all midwifery contacts. Carbon Monoxide (CO) readings are used by midwives to broach smoking cessation and offer support. An opt-out approach is taken, all women are seen within 7 days of referral and support is available throughout the pregnancy.

There is a pathway of care for women who are overweight and pregnant; accessible from NICE Guidelines PH27. Women are supported to maintain a healthy weight throughout their pregnancy as part of the routine antenatal care that they receive. A focus on pre conception support and advice through to antenatal, intrapartum and post-natal services forms the foundation of the Lincolnshire Better Births plan.

A range of universal and targeted public health interventions will be available to support the best start for women and children from preconception to school age. In Lincolnshire best start universal and targeted interventions will focus on:

  • Planning for pregnancy
  • Teenage pregnancy
  • Healthy weight and nutrition
  • Smoking in pregnancy
  • Drinking alcohol in pregnancy
  • Inter-parental relationships and transition to parenthood
  • Domestic violence and abuse
  • Perinatal and infant mental health
  • Breastfeeding
  • Screening and vaccination.

Unmet Needs & Gaps

A current priority is to increase the proportion of women who receive care from the same one or two midwives throughout and following their pregnancy and delivery. This is known as 'continuity of carer', and will enable women to be comfortable with someone and build a relationship with them which grows and deepens over time. This is known to be associated with better outcomes, and importantly will enable a relationship of trust to develop. The aim is for women to be empowered to share their anxieties and insecurities as well as enjoying the more positive aspects of growing in knowledge and confidence through the supported journey of pregnancy.

It has been noted that there is a strong response on social media whenever the Better Births team discuss anxiety and depression following neonatal care. The full extent of the numbers of women affected by these issues is not yet understood, and we have also seen significant engagement from men around these issues. Nationally this is being discussed at length, and methods of better engaging and supporting both mums and dads are being explored.

We know from local service providers that issues such as increased BMI, drug and alcohol use are an increasingly important factor in pregnancy – we need to understand more through collection of data with regard to which groups are most at risk. We know the number of women who are treated for severe post-natal depression through the numbers referred to and treated at the specialist mother & baby unit. However, we lack information on the number of women who suffer from 'lower' level post-natal depression, seek and go on to get help.

Local Views

The Better Births Team for Lincolnshire places a strong emphasis on co design and co-production with women and their families. An integral component of this has been the development of the Maternity Voices partnership. In June 2017 the former United Lincolnshire Hospital Trust Maternity Service Liaison Committee (MSLC), a forum where senior clinicians of all relevant disciplines can discuss with service user representatives the strengths and weakness of the services, became Maternity Voices Partnership (MVP). The aim of the group is to ensure that women, their partners and families are able to give feedback or become members of the group. The group meets bi-monthly across the county and presents a feedback report into the Better Births plan, the feedback will then shape the work of the group including:

  • Setting an annual work plan
  • Engage with the community
  • Connect with ‘seldom heard’ groups
  • Identify and action ‘quick wins’ that make a difference to parents
  • Use social media
  • Adopt walking the patch
  • Use online surveys
  • Parent champion working within Children Centres, and voluntary agencies e.g. Homestart, will explore any issue identified within the feedback. Then by means of social media the group will cascade messages and findings to the wider community.

Communication and engagement in the development of the plan included different ways of involving Lincolnshire's diverse communities including local meetings, attendance at groups and social media.

Engagement and feedback continues through regular Maternity Listening Clinics throughout the county, telephone access and 'get involved' pages on the dedicated Better Births website for Lincolnshire.

This commentary has been produced in collaboration with local providers and commissioners of services; it reflects their key concerns and information wherever it has been possible to back up with appropriate evidence.

Risks of not doing something

Providing timely access to antenatal care and other early support is essential to maintaining a downward trend in infant mortality, and reducing other adverse outcomes in childhood. Reduced access to services such as specialist maternity stop smoking services could lead to an increase in the number of low birthweight babies being born. Any reduction in access to weight management support is likely to lead to even higher levels of maternal obesity and more birth complications.

Pregnancy and early life can help lay the foundations for individual health, well-being, cognitive development and emotional security not just in later childhood but also in adult life. If we fail to support families in laying the best foundations they can for their children, levels of obesity, childhood injury and mental health problems may increase further.

There are significant challenges for maternity services in Lincolnshire; the pattern of families choosing to give birth outside of Lincolnshire may make local services more vulnerable, with the increasing challenge of recruiting and retaining high quality staff in the area. Availability of choice in antenatal and maternity care is highly important but may risk increasing inequalities in access to services. Access to local antenatal care is good within Lincolnshire, but discontinuity of community and acute care brings more challenge in providing seamless services to support mental health needs, continued breastfeeding etc.

What is coming on the horizon?

Community Pharmacies are an important setting for promoting health and wellbeing prior to and during pregnancy. Opportunities to strengthen this include linking pregnancy and maternal health priorities into the Healthy Living Pharmacies.

Opportunities to plan high quality, sustainable services that challenge existing barriers between services over the next five years will develop through the local Sustainability and Transformation Plan.

What should we be doing next?

In line with the 'Better Births' maternity transformation programme, there is a need to expand the choices offered to women. Women who deliver within ULHT are currently offered home or Obstetrics led services, and we are looking to develop Midwifery led units in Lincoln and Boston, as well as developing and expanding the homebirth service to increase access to birth pools.

We will be looking to further develop and expand the Community Hubs, which are now a proven and established model for improving care for women and bringing this care closer to home. The use of digital services such as virtual clinics and technology to support care closer to home – such as mobile scanning – should also be explored.

The Continuity of Carer pilot programme commenced in the Gainsborough area and will continue to develop in other areas. Possible focus for the future is the women who are known type 1 or 2 diabetics or develop diabetes during pregnancy.

Antenatal education and postnatal care will be part of the work for 2019/20, as well as a focus on emotional and physical wellbeing and development of exercise and physiotherapy support.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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