Pregnancy & Maternal Health

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1. 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 affect health, well-being and educational outcomes across the whole life course (Source: Department of Health). During pregnancy and the first few weeks of life, risks to mother and baby can include communicable diseases, physical and mental health problems.  

Whilst women can experience the same mental health problems as the general population during pregnancy and the first few weeks of life, it is especially important to support good mental health during this period because of the impact poor maternal mental health can have on the mother herself as well as on the developing foetus, baby, and wider family. Depression and anxiety are the most common mental health problems during pregnancy, post-partum and in the first year after birth (Source: NICE). Problems are not always disclosed, recognised or treated during this period, making assessment by professionals at all contacts, extremely important. 

Loneliness is the subjective, unwelcome feeling of lack or loss of companionship and is more likely following major life events, such as becoming a parent. People who feel more connected to others have lower levels of anxiety and depression and higher self esteem (Source: Stanford Medicine). Social connection is a fundamental human need, but the extent and type of connection people seek is intensely personal to everyone.  Having opportunities for social connections during and after pregnancy is vital for good physical and mental wellbeing. 

For babies and toddlers, healthy social and emotional development is important in preventing behavioural problems and mental illness later in life, and in supporting possible future educational attainment. 

During a woman’s reproductive years, a continuum of care is required for all stages of the antenatal-maternal journey. Attending a care setting provides professionals with many opportunities to identify and support physical, behavioural, psychological and social risk factors for both mother and baby. For many families, pregnancy and new parenthood is a time to reflect upon health behaviours, with positive behaviours more likely to be adopted during pregnancy (McBride et al, 2003). 

Access to good quality care reduces the risk of adverse outcomes such as pregnancy loss, perinatal death (before 7 days of life) and infant mortality (before 12 months of life), maternal mortality, and low birth weight or premature birth. 

2. Policy Context
  • NICE has produced 30 pieces of guidance relating to pregnancy. Topics include antenatal care, postnatal mental health, diabetes, diet, hypertension, labour, nutrition, postnatal care, and smoking, as well as NICE Guidance and Quality Standards. 
  • NICE has also published guidance on Social and emotional wellbeing: early years [PH40] to demonstrate how social and emotional wellbeing of vulnerable children aged under 5 years can be supported through home visits, childcare and early education. This is supported by a quality standard Early years: promoting health and wellbeing in under 5s [QS128]. 
  • NHS England’s Better Births report reviewed maternity services and concludes the importance  of the need for women and families to be supported in their maternity care choices. The review found that, despite an increasing number of births and an increasing complexity of cases, the quality and outcomes of maternity services have improved significantly over the last decade. 
  • The Healthy Child Programme, first published in 2009, covers pregnancy and the first five years of life with separate guidance covering 5-19 year olds. The delivery model is universal in reach and personalised in response. Guidance focuses on a universal preventative service, providing families with evidence based care, with a programme of screening, immunisation, health and development reviews. The service is supplemented by advice on health, wellbeing and parenting and how health and education services, local authorities and other partners will provide high-quality services for children and young people. 
  • Our local Better Births Plan for Lincolnshire sets out a framework for safe and improving local maternity and neonatal services that recognises and reflects individual personal needs and choices of women and families in Lincolnshire. The vision is to provide maternity services that are safe, personalised, kind, professional and family friendly.  
3. Local Picture

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. The perinatal mental health profile describes a variety of risk factors for poor perinatal mental health. In general, data from Lincolnshire is in line with national averages, but does suggest a focus on sole registered births (% births registered by one parent), rate of stillbirths, the under 18 conceptions rate, the looked after children rate (<5 years old) and statutory homelessness rates. Further guidance regardingchild and maternal health data and intelligencecan be found at the website of the Office for Health Improvement and Disparities. 

The number of live birthsin Lincolnshire has steadily decreased since 2013, from 10.4 live births per 1,000 population down to 8.6 per 1,000 in 2020. Premature births at 37 week gestation has remained similar or below national levels since 2006-08. 

Since 2010, the proportion offull term babies born at low birth weightin Lincolnshire has fallen. This figure has remained below the national and regional level since 2006.  

In Lincolnshire, whilst the overall trend shows a decline over time, the percentage of women who smoke at time of delivery has been significantly higher than the national average since 2010/11. However, due to data quality issues for this indicator, this data should be viewed with caution. 

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

Low birth weight is closely linked to maternal smoking (Source: NHS England). Smoking status correlates strongly with greater deprivation. Therefore, the most vulnerable groups in society are most likely to have poorer health, a reduced quality of life, lower educational outcomes and, overall, a shorter life expectancy. 

Infant mortality is closely associated with health inequalities: deprivation, housing quality and living environment, maternal lifestyle factors, infant feeding choices and, access to services (Source: Department of Health). These inequalities have been potentially influenced by, amongst other things, the education level of the mother, her age, and her income. Crucially, there is no single method of tackling these wide-ranging associations. 

4. Local Response

Community hubs have been developed in Lincolnshire as part of NHS England’s Better Births Maternity Transformation Programme. There are six hubs in Lincolnshire. Purposefully situated in some of the county’s most deprived communities, the hubs have good footfall into their buildings and strong links are being developed with midwifery and health visiting teams. 

The hubs focus on bringing new families together so parents have care close to home, in the community, from their midwife and a range of other services – particularly for antenatal and postnatal care. The hubs ensure families continue to engage with services by visiting the Children Centres. The hubs are targeted for particular groups to address inequalities, e.g. families living in deprived areas or workless households. 

Results have been positive. Attendance at Midwifery clinics and Health Visitor appointments within the centres seem to have supported an increase in attendance for other groups.  For families of 0-2 year olds, the total number of attendances at the children’s centre increased by 20.85% from 2020-21 Q4 to 2021-22 Q4, inclusive of health contacts. Within the last 3 quarters of 2021-22, families’ engagement in a school readiness offer increased by 5% across the county. The benefits of having services all under one roof has been seen by families and professionals. Regular contact with the same group of people has supported the vision for ‘continuity of care’. 

Other Activities & Services

A range of universal and targeted public health interventions are available to support the women and children from preconception to school age. In Lincolnshire this focuses on: 

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

      Early access to care (before 12 completed weeks of pregnancy) maximises opportunities to support women and their partners during pregnancy. It enables potential problems to be identified using a 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. 

      All contacts with pregnant women include an assessment of mental health in accordance with NICE clinical guidance [CG192]. The Perinatal Mental Health Services provide assessment, support and treatment for childbearing women with, or at risk of, serious mental illness, whose care cannot be effectively managed by primary care or other existing mental health services. Perinatal Meantal Health Services also offer advice and assistance to professionals on the treatment and management of serious perinatal mental illness. Additional targeted services, including UHLT’s ‘Birth Afterthoughts’support women and partners who have experienced difficult or traumatic delivery, miscarriage, stillbirth or neo-natal death. 

      Stop smoking services encourage women to make a quit attempt around the time of pregnancy. Cessation advice is incorporated into all midwifery contacts. Carbon Monoxide (CO) readings are used by midwives to broach the topic of smoking cessation enabling them to offer support. An opt-out approach is taken, all women are seen within 7 days of referral with support available throughout pregnancy. 

      A care pathway is in place for expectant women who are overweight based on NICE Guidelines PH27. Women are supported to maintain a healthy weight throughout their pregnancy as part of the routine antenatal care 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. 

      The0-19 children’s health service offers health visiting and nurses to look after the needs of school aged children. Health visitors provide universal care to children and their family from the antenatal period until a 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 an infant during growth and development 
      • Parenting and child behaviour advice 
      • Maternal mental health advice 

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

        5. Community & Stakeholder Views

        The Better Births Team for Lincolnshire emphasises co-design and co-production alongside women and their families. An integral component of this has been development of the Maternity Voices partnership, a forum where senior clinicians of all relevant disciplines can discuss with service user representatives the strengths and weakness of services. The aim of the group is to ensure women, their partners and families are able to provide feedback or become members of the group. The group meets bi-monthly across the county and presents a report to help shape the Better Births plan. The feedback included in the report helps to shape the following work streams: 

        • Setting an annual work plan 
        • Engaging with the community 
        • Connecting with ‘seldom heard’ groups 
        • Identifying and actioning ‘quick wins’ that make a difference to parents 
        • Using social media 
        • Adopting ‘walking the patch’ 
        • Using online surveys 
        • Involving ‘Parent Champions’, working within Children Centres and voluntary agencies e.g. Homestart, who will explore any issue identified within feedback. Then, by means of social media, the group will cascade messages and findings to the wider community. 

          To involve Lincolnshire’s diverse communities, development of the Better Births plan comprises many different communication and engagement activities including locally organised meetings and social media. Regular Maternity Listening Clinics throughout the county provide further opportunities for engagement and feedback and there are ‘get involved’ pages on the Better Births website as well as telephone access. 

          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. 

          6. Gaps and Unmet Needs

          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 build a relationship with a familiar professional that grows and deepens over time. This is known to lead to improved health outcomes and, importantly, should support the development of a trusted relationship. 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 a supported pregnancy journey. 

          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. We have also seen significant engagement from men around these issues. Nationally, methods of better engaging and supporting both mums and dads is a topic of significant importance. 

          We know from local service providers and published evidence that issues including high BMI, drug use and alcohol use are an increasingly important factor in pregnancy. These issues are closely interrelated and can present a cumulative risk to a mother and baby. We need to understand more about where these risk factors are most prevalent amongst women of childbearing age in Lincolnshire to ensure we target services to prevent and effectively tackle health inequalities. We know the number of women who are treated for severe post-natal depression reported by the specialist mother & baby unit. However, we lack information on the number of women who suffer from ‘lower-level’ post-natal depression who seek and go on to get help. 

          7. Next Steps

          In line with the ‘Better Births’ maternity transformation programme, there is a need to expand the choices offered to women. Women who deliver in Lincolnshire have a choice of giving birth at home or in a consultant-led obstetrics unit. Midwifery-led units are being developed in Lincoln and Boston, as well as increasing access to birth pools by expanding the homebirth service. 

          Better Births Lincolnshire are looking to further develop Community Hubs, which are a proven and established model for improving care for women and providing care closer to home. Use of digital services, virtual clinics, and technology, such as mobile scanning should also be explored. 

          The Continuity of Carer pilot programme has commenced in the Gainsborough area and will be developed in further locations. Possible future service development is to offer assistance to women who are known type 1 or 2 diabetics and those that develop diabetes during pregnancy. 

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

          Lincolnshire JSNA People