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

Data Sources:

Supplementary Data Document Published: Dec 2017

NHS Digital Maternity Statistics

Data Profiles: Maternity

Data and Resources: Maternity Needs Assessments

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

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

Royal college of Midwives:

Weight management in pregnancy resource

Linked Topics:

Topic last reviewed: Feb-18

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 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 recent 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 best practice evidence.

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 that went live in October 2017.

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:

  • The number of women accessing care at any time during pregnancy has increased across the county but is starting to slow, please refer to the Supplementary Data Document for further information
  • The National Maternity and Perinatal Audit (NMPA) reports; that of those women whose smoking status at booking was recorded, 14.1% were smoking at the time of booking in England. The % of women who smoke at time of delivery is higher in Lincolnshire compared to England, however, it should be noted that for 2014/15 and 2016/17 data quality issues exist.
  • Despite South Kesteven being the district with the highest number of live births in the county by area of usual residence of mother; and Boston being the lowest in 2016 (Birth Summary Tables, England and Wales); Boston district has the highest General Fertility Rate; and Lincoln the lowest below national and regional levels.
  • Nationally, the number of deliveries taking place in NHS hospitals increased by 1.8% from 2014/15 to 2015/16. Key statistics for the number of deliveries in hospitals can be found in the Maternity Activity, 2015-16 report.
  • For the population of Lincolnshire in 2016, 67% of live births took place in Lincolnshire hospitals (42.2% Lincoln County Hospital, 24.8% Pilgrim hospital and Grantham hospital). However, in the same period, a high proportion of women gave birth in hospitals outside the county; 28% of live births took place at hospitals in counties that border Lincolnshire (13.5% Peterborough, 8.5% Grimsby, 2.9% Nottingham, 2.4% at Kings Lynn and 0.9% Scunthorpe) and 1.5% babies are born in other hospitals. The number of Lincolnshire mothers giving birth at home is increasing with 2.85% being born at home in 2016. However, 0.3% of babies are neither born at home nor at a hospital. (Lincolnshire Birth data 2016 Copyright © 2017, re-used with the permission of The Health & Social Care Information Centre).
  • Full term babies in Lincolnshire are less likely to be of a low birth weight than the England average. Key indicators for: low birth weight of all babies: babies born under 2.5kg: and very low birth weight (under 1.5kg), can be found on the Public Health Profile Pregnancy and Birth.
  • Lincolnshire rates of still birth,perinatal, neonatal mortality and post-neonatal mortality are similar to the England average.
  • Lincolnshire has a significantly lower abortion rate per 1,000 population than England and the East Midlands. Key indicators regarding abortion are available at Public Health Profiles.

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. Based on the number of live births and stillbirths in Lincolnshire in 2016 and the diagnosed mental health conditions rates per 1,000 population by the Joint Commissioning Panel for Mental Health in 2012, it is estimated that the number of women giving birth in Lincolnshire in 2016 suffer from mental health conditions such as postpartum psychosis (15), chronic serious mental illness (SMI) (15), severe depressive illness (225), mild-moderate depressive illness and anxiety (1878), post-traumatic stress disorder (PTSD) (225) or adjustment disorders and distress (3381). This data is only an estimate and its interpretation therefore should be treated with caution.

Further guidance regarding child and maternal health data and intelligence can be found at Public Health England. Additional information regarding perinatal mental health can be found in the Perinatal Mental Health Catalogue and the Perinatal Mental Health Profile.

Trend

Lincolnshire's crude rate (number of live birth per 1,000 population (all person, all ages)) has seen a reduction in the past five years. The General Fertility Rate (GFR) (total number of live births per 1,000 women aged 15-44, calculated using mid-2016 population estimates) in Lincolnshire (59.7) has also fallen in 2016 compared to 2010 (63.2), but is similar to England (62.5) and the East Midlands (60.9). This decline is replicated when looking at the total fertility rate. Population projections show further that the birth rates are likely to remain stable or fall slightly over the coming years.

Since 2005 the proportion of full term babies born at low birth weight in Lincolnshire has fallen from 2.9% to 2.4%, remaining below the national and regional level for the past 10 years, which also saw a reduction. Locally, East Lindsey, Lincoln and Boston districts are amongst those with the highest percentage of babies born with a low birthweight (<2.5 kg) at full term, exceeding the Lincolnshire overall percentage which has remained below the England average since 2006. Babies in the South Kesteven district are less likely to have a low birth weight.

The percentage of babies with very low birth weight (<1.5kg), has fallen since 2010 (1.22%) compared to 2015 (1.16%) and lies below the England and East Midlands averages. Lincolnshire East CCG (1.49%) exceeded the England average in 2015 for the first time since 2010.

The Lincolnshire percentage of delivery episodes, where the mother is aged under 18 years has nearly halved from 2010/11 (2.2%) to 2015/16 (1.2%), but remains above the England average for the same period.

Trends for infant mortality, up to 2013-15, are below the England average across Lincolnshire, except for South West Lincolnshire CCG which lies above the England average. Differences in mortality rates should be viewed over time and with caution due to the small numbers within the data.

Statistics on Women's Smoking Status at Time of Delivery in England shows that 10.8% of pregnant women were known to be smokers at the time of delivery in England (Q1-2017/18) compared to 11.0% for the previous quarter (Q4-2016/17). In Lincolnshire the percentage of women who smoke at time of delivery is above the national level since 2010/11, but is starting to move towards the national percentage in 2016/17, However due to data quality issues for this indicator in 2014/15 and 2016/17 the data has to be viewed with caution.

Recent trends for abortions per 1,000 female population aged 15-44 and under 18s abortions per 1,000 females aged 15-17, show a slight increase in Lincolnshire in 2016, but has remained below the England average since 2012. More background information and advice on tackling teenage pregnancy is provided in Public Health England's joint paper with the Local Government Association (LGA) published January 2016 'Good progress but more to do - Teenage pregnancy and young parents'.

Women having an abortion after a birth, aged under 25 years, in Lincolnshire since 2014 remain similar to England and East Midlands averages, with only 20% being repeat abortion in 2016, thus remaining below the national average. The rate of abortions in women aged 25 and over per 1,000 population in Lincolnshire since 2014, is significantly better than England and the East Midlands. However the percentage of NHS-funded abortions under 10 weeks in Lincolnshire has risen since 2013 and is worse than England and the East Midlands in 2016, with the majority of these abortions being medical abortions, exceeding national and regional levels. National data and detailed commentary on abortion trends are available from Abortion Statistics, England and Wales: 2016.

Key Inequalities

The needs of groups which can be considered vulnerable, such as teenage parents, parents who partake in substance misuse and victims of domestic violence have been fed into plans for the new 0-19 services, responsive to varying levels of need.

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 (2010) 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

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. Detail on access to care is presented in the supplementary data document.

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 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 after thoughts' (Lincoln based) support women who have had a difficult or traumatic delivery, and a ULHT 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 at 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

We know from local service providers that lifestyle issues such as increased BMI, drug and alcohol use are an increasingly important issue in pregnancy – we need to understand more thorough 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 CCG commissioned 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 Plan for Lincolnshire has placed a strong emphasis on ensuring that the plan is co designed and co-produced 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 plans to meet bi-monthly, across the county and present 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 i.e. Homestart, will explore any issue identified within the feedback. Then by means of social media the group will cascade message and findings to the wider community.

A clear message from women and their families was that they would prefer care delivered closer to home, therefore a pilot of four community hubs has been established to test this new model. The local Maternity Voices Partnership will be actively involved in developing and evaluating the pilot programme to ensure that the model of care is right.

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

A previous Healthwatch Lincolnshire survey was conducted in 2016 on ULHT Maternity Services; the sample of patients included was small but provides an in-depth view of services. The main observations made by Healthwatch were that patients were satisfied with the care, both pre and post-natal. In particular, patients interviewed told Healthwatch they felt their care was individual to them, and that they and their partners, and families were supported. In terms of impact, the ability for fathers/partners to stay with the family immediately after births was a huge positive and families felt it was supportive of the bonding process. The survey did identify problems with the physical facilities within ULHT; particularly with regard to the Lincoln site built around the 1960s. The survey highlighted significant challenges including aesthetics of the building, deterioration of fixtures etc. leading to infection control concerns, and a lack of capacity for space and future development.

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?

Plans are well underway to explore how to make the offer from children centres wider, including co-location of services such as the Maternity Hubs pilot described above. This work will continue including education and support for young mothers, first time parents vulnerable mothers & whole families about healthier lifestyles and to base more services in the community thereby reducing the reliance on hospitals and GPs.

Promoting choice and providing information to women when they first become pregnant – Community pharmacies can play a key role in this – also links to Healthy Living Pharmacies.

 

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

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