Joint strategic needs assessment

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Pregnancy

Topic titlePregnancy
Topic ownerLynne McNiven
Topic author(s)Sarah Diggle, Helena Cripps, Uzmah Bhatti
Topic quality reviewed23rd September 2015
Topic endorsed byMaternity Pathway Development Group
Topic approved byMaternity Pathway Development Group
Current versionSeptember 2015
Replaces version2010
Linked JSNA topicsSmoking and Tobacco Control, Adult Mental Health, Teenage Pregnancy, Obesity, Alcohol, Adult Drug Users
Insight Document ID131755

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Executive summary

Introduction

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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.


[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]

 

Unmet needs and gaps

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  • 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

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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.

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.

What do we know?

1. Who is at risk and why?

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1.1 Maternal mortality

Maternal death is fortunately now extremely rare in the UK. In 2009-12, 321 women died during, or within six weeks of the end of their pregnancy in the UK. This represents a statistically significant decrease in the maternal mortality rate, which is now 10.12 per 100,000 maternities[i].

The decrease in the maternal mortality rate is predominantly due to a reduction in deaths due to direct (obstetric) causes. Of the 321 women who died in the UK, just one third (32%) died of complications directly caused by pregnancy; that is conditions like high blood pressure, bleeding or blood clots (figure 1). The majority (68%) of the women who died in this period died from indirect causes, that is medical or mental health problems that were made worse by pregnancy, but not directly caused by pregnancy, such as epilepsy, heart disease, suicide or flu. For example, 1 in 11 of the women died from flu; more than half of these women’s deaths could have been prevented by a flu jab. More than half the women who died were obese, the commonest cause of death being thromboembolism. Cardiac disease was the most common indirect cause of deaths. Although the rate of deaths by direct causes has reduced substantially over the last 10 years, there has been no significant change in the rate of indirect maternal death; MBRRACE-UK recommends urgent action to address deaths from indirect causes3.

In addition, more than two thirds of women who died did not receive the nationally recommended level of antenatal care; a quarter did not receive a minimum level of antenatal care, reinforcing the need to ensure antenatal care is readily and easily accessible.

Figure 1: Direct and indirect causes of maternal deaths in the UK (2009-2012)[ii]

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Set against the backdrop of rising improvements in technology and economic prosperity we may expect that mortality would reduce. However, a number of factors may be working against this:

  • Rising numbers of older mothers
  • Rising numbers of obese mothers
  • Rising numbers of women whose lifestyle puts them at risk of poorer health
  • A growing proportion of women with medically complex pregnancies

In addition to the risk factors for the rare occurrence of maternal mortality, a number of risk factors for maternal and infant health have been identified:

1.2  Vulnerable women with complex social factors

Women with complex social factors are far less likely to seek antenatal care early in pregnancy or to stay in contact with maternity services. Delays in accessing maternity care often results in worse outcomes for both mother and baby. The four key groups (table 1) highlighted in the recent Confidential Enquiry into Maternal and Child Health[iii] reports as having poorer pregnancy outcomes were:

1)    Women who misuse substances (alcohol and/or drugs) - maternal misuse of drugs during pregnancy increases the risk of low birth weight, premature delivery, perinatal mortality and Sudden Infant Death (SIDs)[iv]. Structural damage to the foetus is most likely during 4-12 weeks of gestation; drugs taken later can affect growth or cause intoxication or withdrawal syndromes[v]. Alcohol is classed as a Teratogen which causes harm to the foetus by interrupting the correct coding of amino acids which leads to the development of abnormal proteins and ultimately damages the frontal lobe of the brain. The function of the frontal lobe of the brain is executive function for example development of sensory processes and the development of fine motor skills.

A number of risks are associated with drinking alcohol during pregnancy, including[vi]:

-       Increased risk of miscarriage.

-       Risk of Foetal Alcohol Syndrome (FAS) whose features include: growth deficiency for height and weight, a distinct pattern of facial features and physical characteristics and central nervous system dysfunction.

-       Risk of Foetal Alcohol Spectrum Disorders (FASD), Alcohol Related Birth Defects (ARBD) and Alcohol Related Neurodevelopment Disorder (ARND) – which do not show the full characteristics of FAS and develop at lower levels of drinking.

-       Increased risk of learning disability (without either of the above conditions).

It is estimated that approximately 1% of deliveries are to women with drug misuse problems5 and a similar number to problem alcohol users. A recent cross sectional study found a quarter of women reported drinking alcohol despite being aware they are pregnant report[vii].

2)    Women who experience domestic abuse - A number of studies suggest there can be an increased incidence of domestic violence during or shortly following pregnancy.

3)    Women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English- Black African women including asylum seekers and newly arrived refugees have a maternal mortality rate nearly six times higher than white women[viii]. In addition, it has been found that the proportion of infant deaths is disproportionately higher than amongst other ethnicities. It is estimated that births to African-Caribbean, non-EU and Asian (Pakistan, India, Bangladesh) born women total around 10.2% of total births[ix].

4)    Young women aged under 20 - Teenage mothers are at increased risk due to late presentation and the mother's lifestyle and diet. The proportion of births to women under-20 years in England was 5.2% during 2013[x].

Table 1 gives estimates of live births for the four main exemplar groups of women considered in the guideline on ‘Pregnancy and complex social factors’ (NICE clinical guideline 110).

Table 1: Breakdown of births in England by exemplar group

Group

Percentage (estimate)

Number of births

Women who misuse substances (alcohol and/or drugs)

4.5%

30,200

Women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English

10.2%

68,400

Young women aged under 20

6.1%

40,900

Women who experience domestic abuse

7.0%

47,000

It should be recognised that vulnerable women may experience a number of complex social factors at the same time.

Source: NICE, 2010. Costing statement: Pregnancy and complex social factors5

In addition to the above, the national maternity pathway payment system also identifies the following women with complex social factors as requiring increased support:

•           Pregnant women with a learning disability

•           Pregnant women who are homeless

•           Pregnant women with safeguarding concerns

1.3 Maternal age

The average age of first time mothers was 28.3 years in 2013, compared with 28.1 years in 2012 and the average age of all mothers increased to 30.0 years in 2013, compared with 29.8 years in 2012[xi]. Mothers and their babies at the lower and upper age bands are at greater risk. In England and Wales, pregnancy rates in the older age groups almost doubled in the last 20 years. Older mothers have a greater chance of developing medical disorders such as diabetes, high blood pressure or other chronic diseases. Risk factors for conditions such as Downs Syndrome and other congenital anomalies are strongly related to increasing maternal age and more frequently require screening and intervention. The likelihood of stillbirths and multiple births also increases with the mother's age.

1.4 Multiple births

Multiple births increase the risk of complications for mother and infants; however the rise in the numbers of pregnancies with three or more offspring has reduced with the introduction of tighter policies around assisted conception. 15.6 out of every 1,000 women giving birth had a multiple birth in 2013, down from a peak of 16.1 in 2011[xii]. In 2013, women aged 45 and over were most likely to have a multiple birth (95.0 out of every 1,000 women giving birth in this age group had a multiple birth).

1.5 Maternal obesity and nutrition

1.5.1 Maternal obesity

Maternal mortality and morbidity are strongly related to obesity. Women with a Body Mass Index greater than 40 are particularly at risk. Women who are obese when they become pregnant face an increased risk of complications during pregnancy and childbirth. These include the risk of impaired glucose tolerance and gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and maternal death (Centre for Maternal and Child Enquiries and the Royal College of Obstetricians and Gynaecologists 2010). If a pregnant woman is obese this will have a greater influence on her health and the health of her unborn child than the amount of weight she may gain during pregnancy[xiii].

About half of women of childbearing age are either overweight (BMI 25–29.9 kg/m²) or obese (BMI greater than or equal to 30 kg/m²). At the start of pregnancy, 15.6% of women in England are obese; maternal obesity and weight retention after birth are related to socioeconomic deprivation[xiv].The prevalence of maternal obesity increases with age. Maternal obesity is also a contributor to infant mortality.

1.5.2 Women with vitamin D deficiency

Vitamin D is essential for skeletal growth and bone health. Severe deficiency can result in rickets (among children) and osteomalacia (soft bones) (among children and adults).  A national survey highlights that 24% of children may have low vitamin D status and around a fifth of adults. Dietary sources are limited and the main source of vitamin D is from sunlight on the skin[xv]. NICE guidance PH56 aims to increase supplement use to prevent vitamin D deficiency among at-risk groups; these include:

  • infants and children aged under 5
  • pregnant and breastfeeding women, particularly teenagers and young women

It is recommended that all women are informed at the maternity booking appointment about the importance for of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. Women should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the supplement. Women at increased risk are:

-       Those with darker skin (such as those of African, African–Caribbean or South Asian family origin).

-       Those who have limited exposure to sunlight, such as women who are housebound or confined indoors for long periods, or who cover their skin for cultural reasons[xvi].

1.5.3 Women who have insufficient folic acid intake

There is strong evidence that consuming higher folic acid intakes before pregnancy and in the first 12 weeks of pregnancy will reduce the risk of neural tube defects (NTD) (for example, anencephaly or spina bifida). The body cannot make or store folic acid, so it needs to be consumed or taken regularly.  The recommended dose is 400 micrograms per day. Almost half the pregnancies in the UK are unplanned and even though women are advised to take folic acid supplements many do not, or they start taking them too late. Women in lower socioeconomic groups are the most likely not to meet recommended guidelines regarding folic acid intake[xvii].

800 pregnancies in a year or about 1 in every 1000 pregnancies are affected by NTDs or Spina Bifida; nearly half of these could be prevented by increasing folic acid intake. 

1.6 Smoking in pregnancy

Smoking in pregnancy increases thrombotic risk and risk of pulmonary embolus, a significant cause of maternal deaths. Women who smoke are also at increased risk of miscarriage. Smoking during pregnancy is also associated with a range of serious infant health problems, including lower birth weight (which itself is associated with poorer long term outcomes), premature birth, still birth and perinatal mortality1. Children exposed to smoking in the womb are also at increased risk of infant mortality by an estimated 40% and are more likely to be wheezy, be asthmatic, have problems with their ear, nose and throat and have behavioural issues[xviii].  Compared with other mothers, women who smoke in pregnancy are more likely to be aged under 20 (57%) and from the routine and manual occupational group (40%)[xix].  Mothers aged under 20 are the least likely to give up smoking at some point before or during pregnancy.  Nationally, the proportion of women smoking at the time of delivery is decreasing (table 2).

Table 2 – Decline in SATOD rate from 2006/7 to 2013/14

 

Number of maternities

SATOD (number)

SATOD (%)

2006/7

601,262

90,887

15.1

2013/14

632,956

75, 913

12

Source: HSCIC, (2013/14, published in 2014)

1.7 Perinatal mental health

Development begins before birth, and evidence demonstrates that children born to mothers who experience antenatal stress, anxiety or depression perform at a lower cognitive level and experience more emotional or behavioural difficulties. Parental mental health (before and after birth) is a key determinant of the quality of the parent/infant relationship, and of the ability to provide a number of other conditions for foetal and child development; it is also a key factor in safeguarding children from abuse and neglect2 (also see mental health chapter).

It is estimated that two out of every one thousand new mothers will suffer from a postpartum psychosis and are admitted to a Psychiatric Unit. A further two out of every thousand mothers will be admitted suffering from other serious/complex disorders. All of these require Specialised Mother and Baby Units. 3% of maternities will be referred to Secondary Psychiatric Services; approximately 1% of maternities will require Specialised Perinatal Outreach Teams. 10 to 15% of all delivered women will suffer from mild to moderate postnatal depression, the majority of whom will be cared for in Primary Care.

1.8 Female Genital Mutilation (FGM)

FGM comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women. The practice is most common in the western, eastern, and north-eastern regions of Africa, in some countries in Asia and the Middle East, and among migrants from these areas[xx].

Women who have undergone FGM are much more likely to suffer obstetric complications at childbirth than women who have not been subject to the procedure.  These women have complex needs and often initial access to health care services may be via maternity services. Since the 1st September 2014, it has been mandatory for NHS acute hospital providers to collect data on FGM. For the period of September 2014 to February 2015, there were:

a)    3110 newly identified[1] cases of FGM reported nationally.

b)    46 newly identified cases of FGM reported nationally were under the age of 18[xxi]

The Serious Crime Act 2015 strengthens the law around FGM by extending the extra-territorial jurisdiction of the offence; provides anonymity for victims; creating a new civil protection order; and a new offence of failing to protect a girl from FGM and placing a new duty on professionals to notify the police of such offences.

1.9 High risk pregnancies

Women with certain underlying health conditions such as diabetes and those who have had a previous complicated birth are at increased risk of complications.



[1] Patients first identified during the reporting period as having undergone FGM. This will include those diagnosed/identified within the provider within the month



[i]Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK (2014). Saving Lives: Improving Mother’s Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012. Available at: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf. [Accessed 18.09.15]

[ii] Adapted from MBBRACE UK (2014). Saving Lives: Improving Mother’s Care Executive Summary. Available from: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Exec%20Summary.pdf [Accessed 10.04.15]

[iii] National Institute of Health and Care Excellence (2010) CG110:   Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors. Available at: https://www.nice.org.uk/guidance/CG110/chapter/introduction. [Accessed 18.09.15]

[iv] Standing Conference on Drug Misuse (SCODA) (1997) Working with Children and Families Affected by Parental Substance Misuse London: Local Government Association Publications

[v] Julien, R. (1995). A Primer of Drug Action: A Concise, Non-Technical Guide to the Actions, Uses, and Side Effects of Psychoactive Drugs. 7th Edition. New York: W.H. Freeman and Co

[vi] Abel, E.L. (1998). Fetal Alcohol Syndrome: the American Paradox. Alcohol and Alcoholism, 33 (3), 195-201.

[vii] Smith L, Savory J, Couves J, Burns E (2014). Alcohol consumption during pregnancy: cross-sectional survey. Midwifery Journal Dec;30(12):1173-8.

[viii] Nottingham Insight (2015). Joint Strategic Needs Assessment (JSNA): Asylum seeker  Chapter

[ix] Office for National Statistics (ONS) Quarterly 28 (2005). Available from

http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=15342. [Accessed 24.04.15]

[x] ONS, 2013. Births by Area of Usual Residence of Mother, UK, 2013. Available at: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-327582

[Accessed 17.07.15]

[xi] ONS, Statistical bulletin: Live Births in England and Wales by Characteristics of Mother 1, 2013. Available at: http://ons.gov.uk/ons/rel/vsob1/characteristics-of-Mother-1--england-and-wales/2013/stb-characteristics-of-mother-1--2013.html. [Accessed 24.04.15]

[xii] ONS, Statistical bulletin: Births in England and Wales by Characteristics of Birth 2, 2013. Available at: http://www.ons.gov.uk/ons/rel/vsob1/characteristics-of-birth-2--england-and-wales/2013/sb-characteristics-of-birth-2.html . [Accessed 24.04.15]

[xiii] National Institute for Health and Care Excellence (2011). PH27: Weight Management before, During and After Pregnancy. Available at:  https://www.nice.org.uk/guidance/ph27/resources/guidance-weight-management-before-during-and-after-pregnancy-pdf. [Accessed 24.05.14]

[xiv] Heslehurst, N., Rankin, J., Wilkinson, J. R., Summerbell, C. D. (2010) A nationally representative study of maternal obesity in England, UK: trends in incidence and demographic inequalities in 619 323 births, 1989–2007. International Journal of Obesity 34, 420–428

[xv]National Institute for Health and Care Excellence (2014).  Vitamin D: increasing supplement use among at-risk groups. Available at: http://www.nice.org.uk/guidance/ph56/ [Accessed 24.04.2015]

[xvi] National Institute for Health and Care Excellence  (2008) CG62 – Antenatal Care. Available at: https://www.nice.org.uk/guidance/cg62. [Accessed 18.09.15]

[xvii] Blake M, Herrick K & Kelly Y. Health Survey for England 2002: Maternal and Infant Health. London.TSO, 2003.

[xviii] National Institute for Health and Care Excellence (2010). PH26 Quitting smoking in pregnancy and following childbirth.

[xix] Fiona McAndrew, Jane Thompson, Lydia Fellows, Alice Large, Mark Speed and Mary J. Renfrew (2012) Infant feeding survey 2010. Available at: http://www.hscic.gov.uk/catalogue/PUB08694/Infant-Feeding-Survey-2010-Consolidated-Report.pdf. [Accessed 18.09.15]

[xx] UNICEF (2013) Female Genital Mutilation/Cutting: a statistical overview and exploration of the dynamics of change. Available at: http://www.unicef.org/media/files/FGCM_Lo_res.pdf  . [Accessed  10.04.15]

[xxi] Health and social care information centre, Feb 2015. Female Genital Mutilation (FGM). Available at: www.hscic.gov.uk/fgm. [Accessed 10.04.2015]

 

2. Size of the issue locally

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2.1 Fertility

During 2013, there were 4,298 live births to Nottingham women having risen steadily from 3,540 in 2003 (figure 2); there appears to be a slight decline in the number of births since 2011, however it is unknown if this trend will continue. Figure 3 illustrates estimated live births based on both the current downwards trend and the previous upwards trend.

Capture-(1).JPG

Nottingham has a Total Fertility Rate (TFR) of 1.71 per woman aged 15-44 in 2013; this is equivalent to each woman in Nottingham City having 1.7 babies if the current age specific trends continued throughout her child-bearing life. This is compared to 1.6 in 2006. Nottingham’s TFR is significantly lower than the England average (1.85).

Capture-(2).JPG

Each year during October 2011 – Sept 2014, there were 54.9 births per 1,000 women (aged 15-44 years) in Nottingham City. Local patterns of fertility reflect the distribution of the national birth rates within different occupational groups within the population. The Wards with the highest number of births per 1000 women were in Aspley, Bulwell, Dales and Berridge (figure 4). 

Capture-(3).JPG

Higher pregnancy rates mirror the geographic distribution of teenage pregnancy and are associated with areas of disadvantage. This is where we would expect there to be higher rates of complex health and social needs, need for social support and help with parenting skills.

Table 3 shows that the Children’s Centre area within Nottingham with the highest number of live births (2012) was the Sneinton and St Anns team (877 births) yet the area with the highest rate of births per 1000 women aged 11-44 years was Bulwell and Bulwell Forest.

Table 3: Number of live births (and rate per 1000 women) by Children’s Centre Area Teams (2012)

Children’s Centre Area

Number of live births (2012)

Rate per 1000 women (aged 11-44 yrs)

1.    Bulwell and Bulwell Forest

393

71.7

2.    Basford, Bestwood and Top Valley

675

66.2

3.    Aspley, Bilborough and Broxtowe

678

68.9

4.    Hyson Green and Sherwood

702

52.6

5.    Dunkirk, Radford and Wollaton

583

24.5

6.    Sneinton and St Anns

877

51.5

7.    Clifton and Meadows

534

60.4

2.2 Termination of pregnancy

There were 177,016 abortions to residents of England in 2013. This represents an age-standardised abortion rate of 16.1 per 1,000 resident women aged 15-44[i]. This is the lowest rate since 1997: 0.8% lower than in 2012, 4.7% lower than in 2003 but double the rate of 7.8 per 1000 resident women aged 15-44 recorded in 1970.

During 2013, there were 1,251 abortions to Nottingham women, which is an age standardised rate of 14.7 per 1000 women aged 15-44. This rate is slightly lower than the England rate, although not statistically significant. The age group in Nottingham that had the most abortions was those aged 20-24 (n=433), although those with the highest rate of abortions was the 25-29 age group. During 2013, there were 57 abortions to women aged under 18 years which is a similar rate for this age group in England (12 per 1000 population).

2.3 Miscarriage and stillbirths

A stillborn baby is one born after 24 completed weeks of pregnancy with no signs of life. Stillbirth rates in the UK are higher than might be expected in a high income country: approximately one in 200 babies are stillborn. During 2011-2013, the rate of stillbirths in Nottingham was 4.8 per 1000 births (68 births) which is similar to the England average of 4.9 stillbirths per 1000 births[ii]. Many of these stillbirths are preventable. Although the causes of stillbirths are often unclear, there are associated risk factors[iii],[iv]. These include, but are not limited to:

·         Maternal age (stillbirth rates are highest for women aged under 20 or over 40)

·         Smoking in pregnancy

·         Maternal obesity

·         Socioeconomic position

·         Multiple births

·         Influenza

2.4 Maternal age

During 2012/13, there were 588 births (14.3%) to women aged over 35 in Nottingham. This was significantly lower than the England average (19.2%).

2.5 Maternal mortality

In Nottingham, there were no maternal deaths during 2011-2013. However, it is important not to become complacent; local factors such as the high adult obesity prevalence and the prevalence of smoking in pregnancy increase the risk of a rise in maternal mortality.

2.6 NHS screening in pregnancy

Women are offered five NHS screening programmes during pregnancy (as detailed in section 4.3). Nationally the uptake for the NHS screening programme for infectious diseases is approximately 98%[v].

Table 4: NHS screening programme for Infectious Diseases in pregnancy – incidence of infectious disease nationally and East Midlands region and Nottingham estimate

Infectious disease

National incidence

East Midlands incidence

Estimated number of infected pregnant women in Nottingham per annum*

Hepatitis B

0.6%

0.3%

13

Syphilis

0.1%

0.2%

9

HIV

0.3%

0.1%

6

Rubella infection susceptibility

6.6%

5.1%

219

*Based on East Midlands data

Sickle cell disease and thalassaemia conditions are serious inherited blood disorders and are most prevalent in Black African and Black Caribbean backgrounds[vi].  In 2013/14, approximately 2% of women screened antenatally for sickle cell disease and thalassaemia conditions were identified as screen positive. If this is applied to Nottingham, an estimated 86 pregnant women screened will be identified as positive each year. This is likely to be an underestimation due to the higher proportion of the Nottingham population from Black ethnic groups compared to the England average.

2.7 High risk pregnancies

2.7.1 FGM

Data on the number of Nottingham residents who have undergone FGM is not available. However, during the six month period between September 2014 and February 2015, there were 104 active cases of FGM and an additional 29 newly identified cases reported by Nottingham University Hospital Trust. This will include women who are resident outside of Nottingham City, yet gives a good indication of the prevalence within the local population.

2.7.2 Multiple births

The rate of multiple births is lower in Nottingham than the England average (23.3 births in every 1,000 compared to 31.25 per 1,000 births)[vii]. The likelihood of multiple births increases with age, so this lower rate in Nottingham is likely to be due to the lower proportion of mothers aged 40 and over giving birth.

2.7.3 Diabetes

Data on the number of pregnant women in Nottingham with diabetes was not available. However the National Pregnancy in Diabetes (NPID) Audit commenced in 2013 which provides data at regional level.  Of the six Trusts which participated from the East Midlands (including NUH), the audit identified that there were 154 women with diabetes during pregnancy in 2013[viii].  This will be an underestimation of the true number as not all Trusts in the East Midlands participated in the audit.

2.8 Complex social factors

Table 5 shows the number and percentage of pregnancies to women in Nottingham with complex social factors during 2014/15.

Table 5: Number (and %)of pregnancies to women with complex social factors (2014/15)

Complex social factor

Number (%) of births

(Number of births = 4886)

Aged under 20 years

313 (6.4%)

Recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English

319 (6.5%)

Experiencing domestic abuse

Data not available

Misuse substances (drugs or alcohol)

113 (2.3%)

Learning disability

35 (0.7%)

Homeless

Data not available

Mental health issues

864 (17.7%)

Source: NUH Medway Maternity data

Further information on local need the four priority social factors highlighted by NICE is summarised below.

2.8.1 Mothers aged under 20 years

According to NUH maternity data, during 2014/15, there were 313 maternity bookings to women aged under 20 years. There were 81 births (2%) to teenage mothers (aged 12 to 17) which is higher than the national average of 1.2%[ix].  Figure 5 illustrates that both Bulwell/Bulwell Forest and Aspley/Bilborough/Broxtowe Areas have statistically significant higher rates of teenage pregnancy than the City average and only the Dunkirk/Radford/Wollaton Area has a significantly lower rate than the City average.

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2.8.2 Recent migrants, asylum seekers and women who have difficulty reading and speaking English

The rise in fertility rates as in part, been due to increased migration. Ten countries joined the European Union in 2004, and another two in 2007. In 2013, 32.7% of Nottingham’s births were to mothers born outside of the UK, a slight increase from 2012 (31.8%), and more than double the percentage in 2001 (14.5%)[x].

The Office for National Statistics (ONS) estimated that the City gained 5,190 people due to international migration in 2013/4 alone. The number arriving from the EU Accession countries was 2,690. The majority of these were from Poland (1,750) but there was a notable increase in migrant workers from Romania (320 - up from 83 the previous year). However, migration flows from Eastern Europe have slowed down in recent years[xi]. Migrants from EU Accession countries were predominantly aged less than 35 years old.

In October 2014, there were 779 asylum seekers residing in Nottingham city who have been assessed as destitute and are in receipt of housing or financial support from UK Visas and Immigration (UKVI) (Formerly UKBA). This figure excludes asylum seekers who are not assessed as destitute, refugees, failed asylum seekers and unaccompanied minors. This data provided by the Home Office provides a point prevalence of the number of asylum seekers receiving support at any one time, and does not show the number of asylum seekers arriving in an area, or the number ceasing to receive support due to either positive or negative asylum decisions. This number has increased steadily over the last year. Numbers are expected to continue to rise: the Home Office anticipates a 10-15% rise over the course of 2015 in the number of asylum seekers requiring support. More detail is given in the Asylum seekers, refugees and migrant workers chapter of the JSNA. There is some evidence to suggest that migrants defer starting a family until reaching the host country accounting for a higher pregnancy rate in these groups (Chamberlain 2005).

2.8.3 Women who experience domestic abuse

In Nottingham (2013/14), there were 38 domestic violence and abuse related calls to police per 1000 population compared to the England average of 19 per 1000[xii].  In terms of domestic violence crimes, there were an estimated 6.8 per 1000; however it is estimated that only 40% of offences are reported to the police, so this is likely to be a significant underestimate of the true prevalence of domestic violence.

Using the NICE estimate[xiii] regarding the number of women who experience domestic abuse during pregnancy (7%), it is estimated that 306 pregnant women in Nottingham experience domestic abuse each year. In 2013/14, the Children’s Centre area with the highest rate of domestic abuse related calls to the police was the ‘Aspley, Bilborough and Broxtowe’ area, followed by ‘Bulwell and Bulwell Forest’ and ‘Bestwood, Basford and Top Valley’ (figure 6).

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2.8.4 Alcohol and drug use

There is an underestimation of alcohol consumption among pregnant women because data on rates of alcohol consumption during pregnancy are commonly based on self-reporting. Such reporting is unreliable because of poor estimation, poor recollection and the social stigma associated with heavy drinking during pregnancy[xiv].  Comprehensive local data on alcohol consumption in pregnant women is not available.

According to the Nottingham Citizen survey, 2014, it is estimated that more than a quarter (25.8%) of women of child bearing age (16 – 44 years) are binge drinkers[1]. It can be assumed that women who are planning a pregnancy may reduce their alcohol consumption; however this remains a concerning percentage, particularly given that half of pregnancies in the UK are unplanned.

As shown in table 5, 113 pregnant women during 2014/15 were reported to misuse drugs or alcohol. How this is proportioned to drugs and alcohol is unknown, Also, this is likely to include only those with significant drug or alcohol issues and therefore be an underestimation of drug/alcohol misuse during pregnancy.

2.9 Smoking in pregnancy

According to the Nottingham Citizens’ Survey, 2014, there is very high smoking prevalence in the City adult population (27%).

Historical year on year reductions in smoking rates in pregnancy have not been maintained and smoking status at time of delivery (SSATOD) rates in all pregnant women have remained fairly static since 2007/8.  In 2013/14, 18.5% of Nottingham women were reported to be current smokers at the time of delivery, significantly higher than the England average (12%) (figure 7).  Maternity data suggests that during the same year, 889 (19.7%) pregnant women were current smokers at the time of their maternity booking appointment which suggests that few women stop smoking following this stage of pregnancy.

Figure 7: SSATOD in Nottingham compared to England (2010/11 -2013/14)32

Capture-(6).JPG

Figure 8 shows that Nottingham has one of the highest percentages of women smoking at time of delivery when compared to its statistical neighbours. During 2013/14, 799 women were reported to be smokers at the time of delivery.

Figure 8: SSATOD in Nottingham compared to statistical neighbours and England (2013/14)

Capture-(7).JPG

SSATOD data at ward level is not available. The Nottingham Citizen Survey however estimates that 29.7% of women of child-bearing age (16-44 years) in Nottingham smoke. The Children’s Centre area with the highest prevalence among women of child-bearing age is the Bulwell and Bulwell Forest team area (45.4%) followed by Aspley, Bilborough and Broxtowe (37.1%) then Clifton and Meadows (36.1%) (figure 9).

Figure 9: Estimated smoking prevalence among women of child-bearing age (16-44 years) by Children’s Centre Area with 95% confidence intervals (2014)

Capture-(8).JPG

Performance monitoring data from the Family Nurse Partnership indicates that 41.8% of FNP clients during 2013/14 were smokers (had smoked within last 48 hours) at the time of initially accessing FNP. This very high prevalence amongst FNP clients suggests that a more focused approach may be required for teenage parents.

2.10 Maternal nutrition and obesity

Obesity

Model based estimates for the proportion of women in the different BMI categories were calculated using unpublished data from the study by Heslehurst et al (2010) (table 6). Using this method it is estimated that obesity prevalence during pregnancy in Nottingham is 17.7% which is higher than the England average (15.6%). The estimate suggests that there are approximately 773 obese pregnant women in Nottingham each year (681 obese and 92 morbidly obese).

As with the adult obesity estimate, this higher obesity level estimate amongst pregnant women is probably due to the high proportion of Nottingham City being within the most deprived fifth of England.

BMI is now being systematically recorded by the NUH maternity services. This is collected for women with either a BMI over 35 or a BMI under 18. During 2013/14, NUH report that 368 (8.6%) of pregnant women in Nottingham had a BMI over 35 and 146 (3.4%) had a BMI under 18.  It is difficult to compare this to national estimates as data was not available for all BMI categories. Data on women with a BMI over 30 would be beneficial in fully understanding prevalence.

Table 6: Model based estimate of maternal BMI categories in Nottingham City compared with England (based on unpublished statistics from Heslehurst et al (2010)

BMI Category

England prevalence 2007

Local Estimated Prevalence

Underweight (BMI<18.5)

4.9%

5.3%

Healthy Weight (BMI ≥18.5-24.9)

53.6%

50.7%

Overweight (BMI ≥25-29.9)

25.9%

26.3%

Obese (BMI ≥30)

15.6%

17.7%

Morbid obese (BMI≥40)

1.4%

2.1%

Nottingham Citizen’s Survey estimates that 31% of women of child-bearing age (16-44 years) are overweight, obese or morbidly obese. This estimate ranges from 21% in the Dunkirk, Radford and Wollaton Children’s Centre Area to 44.7% in Aspley, Bilborough and Broxtowe (figure 10). These estimates demonstrate that the prevalence of obesity is a key issue for maternal and infant health in Nottingham.

Figure 10: Percentage of Nottingham women (aged 16-44 years) who are estimated to be overweight, obese or morbidly obese by Children’s Centre Area (with 95% confidence intervals) based on the Citizen’s Survey 2014.

Capture-(9).JPG

Vitamin D and Folic acid

Accurate data on the use of folic acid and vitamin D among pregnant women in Nottingham is not available.

2.11 Maternal mental health

Based on national estimates, the number of mothers in Nottingham experiencing mental health conditions is given in table 7.

Table 7:  Estimates of mental illness in post-partum mothers, Nottingham City

 

Prevalence

Per 1000 maternities

Number of maternities (Nottingham city 2012)

Estimated number of cases per year

Post-partum psychosis

2

4368

9

Chronic serious mental health

2

4368

9

Severe depressive illness

30

4368

131

Mild-moderate depressive illness and anxiety states

100-150

4368

437-655

Post-traumatic stress disorder

30

4368

131

Adjustment disorders and distress

150-300

4368

655-1310

Number of maternities,4368: live births, 4408: Source ONS

Due to local social and economic deprivation, it is assumed that the true numbers may be substantially higher. Data from NUH Maternity Services show that during 2014/15, 864 (17.7%) pregnant women in Nottingham had mental health issues. This includes all women that are assessed as requiring specialist support for their mental health and will therefore not include women with low level mental health problems.

The above data is not available by Ward or a smaller geographical area. However data from the Nottingham Citizen’s survey, 2014, estimate that the Children’s Centre Area with the highest proportion of women of child-bearing age (16-44 years) with poor mental health is Aspley, Bilborough and Broxtowe, where more than one in five (21.8%) reported to have poor mental health (figure 11). This is statistically higher than the City average (13.2%). Dunkirk, Radford and Wollaton is the only area with a significantly lower proportion of women of child bearing age with poor mental health (8.8%), although confidence levels are wide which may be masking true differences across areas.

The above data from various sources illustrates the substantial issue that maternal mental health is for Nottingham and likely inequalities across the City.

Figure 11: Percentage of women (aged 16-44 years) with poor mental health by Children’s Centre Area (and 95% confidence intervals) (2010-2013)

Capture-(10).JPG

Summary of need

From the demography outlined above and what is known about prevalence of risk factors and current data, we can deduce that Nottingham has above average maternal health needs. The relatively younger population and age at which women give birth may lead to an expectation of better health outcomes and less need for health care resources. However, a high proportion of women have complex social factors which impact on maternal wellbeing and pregnancy outcomes. Meeting these needs requires good access to primary care, an adequately staffed and accessible midwifery service supported by midwifery and family support workers and other partners including the third sector to meet the extended needs of the population, including access to culturally sensitive clinics and translation services.


[1] Defined as consuming six or more units of alcohol at one time/in a day



[i] Department of Health (2014).  Abortion Statistics, England and Wales: 2013. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/319460/Abortion_Statistics__England_and_Wales_2013.pdf. [Accessed 10.04.2015]

[ii]Chimat (2015) Service Snapshot-Infant Mortality and Stillbirths for Nottingham. Available from: http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=59&geoTypeId= [Accessed 27.04.2015]

[iii] Department of Health. Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays (Internet). London: DH; 2013 (cited 2014 Nov 11). Available from: https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-prevention-pays. [Accessed 10.04.15]

[iv] NHS Choices (Internet). NHS. Stillbirth- causes; (reviewed 2013 Feb 22; cited 2014 Nov 11). Available from: http:// www.nhs.uk/Conditions/Stillbirth/Pages/Causes.aspx. [Accessed 10.04.15]

[v] Public Health England (2014). National Antenatal Infections Screening Monitoring: annual data tables. Available from: https://www.gov.uk/government/publications/national-antenatal-infections-screening-monitoring-annual-data-tables. [Accessed 10.04.15]

[vi] Public Health England (2015). NHS Sickle Cell and Thalassaemia Screening Programme:

 Data Report 2013/14 Trends and performance analysis

[vii] Chimat (2105). Service Snapshot – maternity. Available at: http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=10&geoTypeId=[Accessed 18.09.15]

[viii] Health and Social Care Information Centre, 2014. National Pregnancy in Diabetes Audit Report 2013 - East Midlands. Available at: http://www.hscic.gov.uk/searchcatalogue?productid=16021&q=%22National+Pregnancy+in+Diabetes+audit%22&sort=Relevance&size=10&page=1#top. [Accessed 17.07.15]

[ix] Public Health England (2015). Public Health Outcomes framework data tool. Available at: http://www.phoutcomes.info/. [Accessed 18.09.15]

[x] Office for National Statistics Live births by country of birth of mother and area of usual residence 2012. Available at:

http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-320361 and 2001 to 2009: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-39699. [Accessed 17.07.15]

[xi] Nottingham Insight (2015) Joint Strategic Needs Assessment: Demography Chapter 2015

[xii] Nottingham Crime and Drugs Partnership (2015). www.nottinghamcdp.com

[xiii] NICE (2010) Costing statement: Pregnancy and complex social factors. Available at: https://www.nice.org.uk/guidance/cg110/resources/cg110-pregnancy-and-complex-social-factors-costing-statement2. [Accessed 18.09.15]

[xiv] Plant ML, Miller P, Plant M (2005). The relationship between alcohol consumption and problem behaviours: Gender differences among British adults. Journal of Substance Use 10: 22–30

 

3. Targets and performance

Back up to the contents

Nottingham Plan

The Nottingham Plan (Nottingham City Council, 2015) has various targets around adult health which would contribute to improved maternal health. These include:

·         Reduce smoking prevalence to 20%

·         Reduce the proportion of overweight and obese adults to the 2000 average levels for

·         England, 60%

·         Increase levels of physical activity to 32% of adults participating in 3 x 30 mins moderate physical activity per week

·         Reduce alcohol related hospital admissions to 1400 per 100,000 population

·         Improve mental health and wellbeing across the city

Nottingham Children’s and Young People’s Plan (CYPP) (2015/16)

‘Promoting the health and wellbeing of babies, children and young people is one of the priorities of the CYPP. The following indicators related to this chapter are included around ‘Good maternal health and healthy babies’:

• % of women reporting smoking at the time of delivery

• % of women receiving a perinatal mental health assessment during their pregnancy at booking

• % of women receiving a perinatal mental health assessment after 28 weeks of pregnancy

•Rate of infant mortality per 1,000 live births (aged under 1 year) is included:

Public Health Outcomes Framework (PHOF) 2013-2016

There are indicators in the PHOF related to pregnancy and maternal health as shown in table 8. Please note that other than infant mortality, indicators for infants will be included in the 0-5 JSNA chapter.

Table 8: PHOF indicators related to pregnancy, and current performance compared to England

Domain

Indicator

Current performance

England average

Comparison

Wider determinants of health

Domestic abuse

22.3 per 1000

19.4 per 1000

This is not compared for statistical differences due to data quality

Health improvement

Smoking status at time of delivery

18.5%

12%

Statistically higher

Under 18 conception rate

37.5 per 1000 (age 15-17)

24.3 per 1000 (age 15-17)

Statistically higher

Antenatal infectious disease screening -HIV

98.9%

Not available

Unknown

Antenatal sickle cell and Thalassaemia screening coverage

98.9%

Not available

Unknown

Healthcare and preventing premature mortality

Infant mortality

5.2 per 1000 live births

4.0 per 1000 live births

Statistically higher

 

NHS Outcomes Framework 2015/16

Indicators related to pregnancy in the NHS Outcomes Framework include:

  • Preventing people from dying prematurely domain:
  • Infant mortality
  • Neonatal mortality and stillbirth
  • Ensuring that people have a positive experience of care domain
  • Improving women and their families’ experience of maternity services
  • Treating and caring for people in a safe environment and protecting them from avoidable harm
  • Improving the safety of maternity services - Admission of full-term babies to neonatal care

CCG Outcomes Framework 2014/15

The outcomes framework for CCGs had two indicators relating to pregnancy in 2014/15[i]

  • Maternal smoking status at time of delivery.
  • Antenatal assessments before 12 weeks and 6 days

Social Care Outcomes Framework

The social care outcomes framework does not contain any specific indicators relating to pregnancy.



[i] NHS England 2015. Clinical Commissioning Group Outcome Indicator Set (CCG OIS). Available from: http://www.england.nhs.uk/ccg-ois/ [Accessed 13.05.2015]

 

4. Current activity, service provision and assets

Back up to the contents

Nottingham City Council, Nottingham City CCG and NHS England are currently undertaking a Strategic Child Development Review (CDR) which aims to make recommendations to inform the development of an integrated and evidence-based child development offer for universal and early help services and approaches that will support health, social and educational outcomes for pregnant women, babies, children and young people and their families in Nottingham within the resources available. The CDR Governance Group oversees this process.

In addition, there are the following strategic groups in the City that are supporting the maternities and pregnancy agenda:

·         Partnership in Maternity Steering Group – a partnership group to support the development of maternity services across Nottinghamshire and Nottingham City.

·         Maternity Review Implementation Group – to oversee the implementation of the Maternity Review Action Plan in line with evidenced based practice and national policy drivers.

·         Health Visiting and FNP Transition Board – to oversee the smooth and safe transition of the commissioning of 0-5 public health services from NHS England to Local Authority. Following the transition, this group will continue to oversee the continued development of 0-5 public health services.

·         Smoking in Pregnancy Steering Group - aimed at reducing the prevalence of smoking in pregnancy across Nottingham City and Nottinghamshire South. 

·         Alcohol in Pregnancy group - established in 2014 to develop a co-ordinated approach to preventing and reducing alcohol related harm in pregnancy promoting the view that ‘No Alcohol equals No Harm’

·         FGM Board was established early in 2015 to establish robust governance for this important issue. There is also a well-established community steering group.

4.2 Pregnancy pathway

Integration, relationships and shared pathways are essential in caring for pregnant women and babies. The importance of midwives contribution cannot be understated to ensure the best possible health outcomes and start in life.  It is particularly critical that there is integrated working between midwives, health visitors, family nurses  and Early Help services provided through Children’s Centres. Information sharing across organisational boundaries is vital for continuity of care and safeguarding.

 

There are several service providers along the pregnancy pathway and commissioning arrangements have recently changed from April 2013 with further changes to come into effect in October 2015/16. For clarity, the provider and commissioner of key services are listed in Table 9:

 

Table 9:  Commissioners and providers of services  for  the pregnancy pathway          

Service

Provider

Commissioner 2013/14

Commissioner 2015/16

Maternity Services

Nottingham University Hospitals NHS Trust

NHS Nottingham City CCG

Unchanged

Health Visiting

Nottingham CityCare Partnership

NHS England

Nottingham City Council

Family Nurse Partnership

Nottingham CityCare Partnership

NHS England

Nottingham City Council

Early Help Services (provided through Children’s Centres)

Nottingham City Council/Voluntary Sectors Providers

Nottingham City Council

Unchanged

General Practice

Various

NHS England

Unchanged

Public Health interventions

Various

Nottingham City Council

Unchanged

 

4.3 NUH - Maternity services

Maternity services in Nottingham are commissioned from Nottingham University Hospitals (NUH) and provide community midwifery services, obstetric care, and manage the whole midwifery service.

Current services therefore aim to:

·         Ensure all women receive appropriate information and support during pregnancy to improve their own health and that of their unborn child

·         Ensure all women with complex social care needs (e.g. substance misuse, domestic violence) are assessed and given appropriate support.

·         Ensure pregnant women with mental health problems have equitable access to specialist services.

·         Increase early engagement of interagency partners in integrated support for pregnant teenagers and their partner.

4.2.1 Maternity pathway tariff

A mandatory Maternity Pathway Payment System came into effect from April 2013 with the aim of encouraging a more pro-active and woman-focused approach to the delivery of maternity services.  Under the new system, commissioners pay the provider for all the pregnancy-related care a woman may need for the duration of her pregnancy, birth and postnatal care. The main emphasis of the new system is to ensure that women receive the highest quality, proactive maternity care that delivers the best outcomes and experience and prevents the onset of avoidable conditions and complications. This new system removes the financial reward for undertaking all interventions in a hospital setting.

4.2.3 Maternity Access

Early access to maternity care is an important opportunity for healthcare professionals to interact and build relationships with women and families who, although in most need would not otherwise access health services. Early access is essential to ensure that women have the best support to ensure early risk assessments, accurate assessment of gestation, uptake of folic acid and Vitamin D, access to screening and foetal medicine/foetal anomaly screening services, monitoring of the baby’s growth and development and a focus on the mother’s health & wellbeing, including lifestyle factors such as diet, physical activity, smoking, drugs and alcohol.

NICE Quality Standard for Antenatal Care (QS22) outlines that pregnant women need to be supported to access antenatal care, ideally by 10 weeks 0 days. Previous targets have recommended access by 12 weeks and 6 days.

During 2014/15, 78.5% of women whose births were registered in Nottingham City were booked and seen before 12 weeks 6 days gestation against a target of 90%. This appears to be significantly lower than previously reported in 2012/13 (94.2%). However due to changes in data collection systems it is not possible to compare this data. It is thought that the true percentage accessing within the 12 weeks and 6 days may be higher than that reported and work to resolve data collection issues is ongoing.

The 10 week access target will be challenging to achieve in the city; currently 36.5 % of women access within this time. A targeted campaign promoting direct and early access to midwives is being initiated in 2015/16.

NICE guidance for pregnancy and complex social factors (CG110) outlines that facilitating early booking for women with complex social factors is even more important than for the general population of pregnant women.  We would therefore hope that a higher percentage of women with these factors were accessing maternity services early than the general population.

However, it appears that recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English are particularly vulnerable with only 52% accessing maternity (booking) within the recommended gestation. When this group is broken down into the three separate factors, it is noteworthy that of the 10 births to asylum seekers or refugees, 9 (90%) accessed maternity services later than recommended and all of these accessed after 20 weeks gestation.

Table 10: Time/gestation of maternity bookings for women with complex social factors(2014/15)

Complex social factor

Number of maternity bookings

 

Number (%) booking by 12Wks +6

Number (%) booking late (13Wks+)

Number (%) booking Over 20Wks*

Aged under 20 years

313

227 (72%)

74 (24%)

34 (11%)

Recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English

319

166 (52%)

152 (48%)

86 (27%)

Recent migrants

29

5 (17%)

24 (83%)

21 (7%)

Asylum seekers or refugees

10

1 (10%)

9 (90%)

9 (90%)

Difficulty reading or speaking English

280

160 (57%)

119 (43%)

56 (20%)

Experiencing domestic abuse

Data not available

Misuse substances (drugs or alcohol)

113

89 (79%)

23 (20%)

6 (5%)

Learning disability

35

29 (83%)

6 (17%)

2 (6%)

Homeless

Data not available

Mental health issues

864

706 (82%)

150 (17%)

52 (6%)

*These women are also included in the previous column (number booking late)

Source: NUH Medway Maternity data

4.2.4 Midwifery and Communication

Midwives inform the GPs of booking via a confirmation of booking letter which is generated from SystmOne.  A Core Offer to GPs was made by NUH in 2012 and part of this involves the development of bespoke communication routes with each practice and the allocated of a named midwife at each practice. If there are any complications in pregnancy information is shared in the way agreed between each GP practice and their midwife. 

4.2.5 Midwifery services for women with complex social factors

NICE guidance identifies that pregnant women with complex social factors may have additional needs and outlines the following barriers to them accessing antenatal services:

·         They are overwhelmed by the involvement of multiple agencies

·         They are not familiar with antenatal care services

·         They have practical problems that make it difficult for them to attend antenatal appointments

·         They find it hard to communicate with healthcare staff

·         They are anxious about the attitudes of healthcare staff

NUH have specialist midwives for substance misuse, young parents, those who are homeless and those experiencing domestic abuse. Specialist midwives focus on engagement and retention of pregnant women. They provide antenatal and postnatal care for women who are the most at risk and provide support and training for the wider workforce. In addition there are midwives with specialist interests in targeted areas that include a range of complex social factors; this activity is delivered in addition to midwives clinical roles supported by dedicated time.

Pregnant women who misuse substances (alcohol and/or drugs)

All women are asked about alcohol and substance misuse at maternity booking. A positive answer would lead to repeated questioning, support, advice or referral at every appointment. The national Audit C tool[i] has recently started to be completed for every pregnant woman at booking and data will be reported in future updates of this chapter. All women receive a brief intervention and the client is given an alcohol in pregnancy leaflet.

There are 1.8 WTE Specialist Midwives for substance misuse. For all cases, an assessment is made as to whether the specialist team case hold, share care with the community midwife, or act as an advisory capacity in a woman’s maternity care. Clients that are referred into the specialist substance misuse team are fast tracked into substance misuse services, recently renamed as Recovery in Nottingham and care delivered in line with NUH guidelines for Drug Misuse in pregnancy. Data on the number of women accessing Recovery is not available.

Currently women are not routinely asked about their alcohol and substance misuse again at 28 weeks if they offered a negative answer at booking as per NICE guidance.

Pregnant women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English

Language barriers are assessed at booking and interpretation initiated as appropriate via face to face or telephone interpreting services. NUH have developed guidance regarding how to prioritise face-to-face interpretation which includes the booking appointment, 16 weeks, 28 weeks and 36 weeks. A practice guidance template has been developed to reflect who women agree to help with translation and support in an emergency situation (friend or family member).

NICE recommends that all women should be provided with an interpreter for all their maternity care. Assurance is required that the service encourages face to face interpretation and ensures telephone interpreting is used as a minimum at each appointment, and a family member, legal guardian or partner is not be used as an interpreter in the antenatal or postnatal period unless in an emergency.

Young pregnant women aged under 20

NUH has a teenage pregnancy team, who have traditionally accepted referrals for those under the age of 17 years or those under the age of 19 years where additional needs are identified. The team have expanded to work with all young women under the age of 18.

Additional needs constitute any young women under the age of 19 who have two high-risk factors (i.e. care leavers, learning disabilities), or anyone under the age of 19 with three moderate risk factors (i.e. homeless, substance misuse, youth offenders, mental health problems, social care/safeguarding issues).  If a generic midwife identifies that a young person would particularly benefit from additional support, this too is accepted by the teenage pregnancy team. The teenage pregnancy midwives support young women throughout the antenatal and postnatal period, extending support on the core midwifery offer to support women 6 weeks postnatally. Care is offered flexibly to support young women to continue to access education.

Data on the number of young women access the NUH teenage pregnancy team per annum was not available.

Pregnant women who experience domestic abuse (and pregnant women who are homeless)

There is one WTE Specialist Midwife for homelessness and domestic abuse; around a quarter of the role is clinical, providing antenatal and postnatal care for a small defined caseload of complex women. The specialist midwife also provides support to midwives to enable them to give additional care to women on their caseloads who are victims of domestic abuse or who are homeless or at risk of homelessness. The post supports staff regarding completion of risk assessments and disclosures of domestic violence and supports the provision of information to the Domestic Abuse Referral Team (DART). The post holder also attends MARAC meetings for pregnant women considered the most high risk and help to formulate a multiagency action plan to safeguard the family.

All midwives have received training on routine enquiry and best practice is for at least three enquiries per pathway.

Pregnant women who have undergone female genital mutilation (FGM)

There are numerous pieces of guidance on the care and treatment of women who have undergone FGM.  Women who have undergone FGM are most likely to be identified through maternity services. At booking, maternity health professionals have an opportunity to sensitively enquire about FGM, and once identified, to respond to the woman’s complex needs, and refer appropriately. The Royal College of Nursing issues specific guidance on FGM and notes that certain health and teaching practitioners are well placed to enhance early intervention.  There is a FGM specialist midwife who holds clinics for women who have undergone FGM. Data on the number of women accessing this service was not available.

Pregnant women who have a learning disability

All midwifery teams have a resource box with information appropriate to use with women or families with a learning disability. This includes the ‘my next patient has a learning disability’ toolkit, the NHS Midlands and East ‘Top tips for supporting and meeting the needs of people with profound and multiple learning disabilities’ and ‘the hospital communication book’. There is also a midwife with a specialist interest in Learning Disability available to provide support and raise awareness across the maternity pathway.

Gestational diabetes

Currently pregnant women are risk assessed for gestational diabetes at their first appointment with a midwife. Women identified at risk using the current NICE Guidelines are referred for an antenatal Glucose Tolerance Test (GTT) between 24-28 weeks or earlier if indicated. If women not referred for a GTT, develop glycosuria in their pregnancy, they will be referred for screening. Doctors may refer during pregnancy if they pick up large for dates babies and polyhydramnios on scan.

4.2.6 Maternity Workforce

Midwifery staffing establishments are often measured via a midwife to birth ratio. The Royal College of Midwives recommends that all midwifery units should work towards a ratio of 1:28 WTE midwives to births (this calculation includes acute and community midwives). The Birthrate Plus acuity tool, which adjusts for local factors, determines that a ratio of 1:29 midwives to births is required at NUHT. This ratio was largely achieved across 2014/15.

NUH have challenges recruiting experienced and community midwives however this is not a situation unique to Nottingham.

A practice development/clinical educator team of 9 midwives are responsible for coordinating a comprehensive education programme for maternity services. Training for midwives is driven by CNST, CQC or NUH standards and guidance and there is also maternity specific training provided. Learning Beyond Registration is available for any midwife and is offered with East Midlands Local Education and Training Board (LETB) funding at Nottingham University, up to 60 midwives per annum begin courses.

NUH are committed to increasing the consultant obstetric workforce by an additional one WTE consultant per annum, including a commitment for any consultants recruited to work out of hours. This responds to national guidance recommending increased consultant presence on the labour suite and the increasing complexity of the caseload.

4.2.7 Information systems

Information technology requires significant development. Community equipment and hardware should be upgraded as community midwives struggle to access systems in the community which impacts on capacity of the service. Connectivity in the community should be improved including at some children’s centres.

The acute maternity system, Medway, should be implemented in the community to enable maternity records to be accessed and updated from a range of locations. Currently community records are updated on SystmOne, which may be on return to a midwife’s base, and paper copies of information sent to NUH clerks for entry to Medway. This introduces delay and opportunity for inaccuracy. The same level of information needs to be accessible to midwives working in the community and acute settings, and information technology solutions are required to achieve this, whilst ensuring information sharing to universal and community health services is not compromised.

4.2.8 New Maternity Service Developments

Services have been reviewed to ensure that they are meeting the recommended requirements in Maternity Matters as set out below.

-       Antenatal and postnatal care will be offered in a number of settings. This takes place in Nottingham City, with the options of GP practices, Health Centres and Children’s Centres.

-       Clinical and social needs will be assessed on an ongoing basis through the pregnancy with appropriate referral to specialist medical and social care support services when required.

-       A named midwife will help each woman access these services and will be the lead coordinator for all her maternity and new-born care. Women will have a main point of contact throughout their pregnancy (this already takes place in Nottingham City and will improve consistency of service delivery).

-       Women will be offered more birth choices based on their needs (this already takes place in Nottingham City).

-       Additional midwife-led facilities will be available in hospitals, within the current financial envelope.

-       Intensive care for the most critically ill babies will be at the Queens Medical Centre and care for the less critically ill babies will continue to be provided at the City Hospital campus (aligning service delivery with the recommendations from the East Midlands Specialised Commissioning neonatal review).

-       Development of ‘Pocket Midwife’ app which provides basic information about pregnancy and labour with useful links.

4.3 Antenatal Screening

The UK NSC Screening Programme is responsible for developing, implementing and maintaining a high quality, uniform screening programme for all pregnant women in England. Screening is an integral part of midwifery to enable expectant mothers to make decisions regarding their unborn baby’s health. All women should be offered the 7 UK NSC programmes:

o   NHS Infectious Diseases in Pregnancy Screening (IDPS) Programme- ensuring that all pregnant women are routinely offered screening for hepatitis B, HIV, syphilis and susceptibility to rubella infection.

o   The NHS Down’s syndrome screening programme aims to offer all women a screening test for Down’s syndrome and to provide information for women so that they are able to exercise informed choice.

o   NHS Fetal Anomaly Screening Programme (NHS FASP) - offers all pregnant women a minimum of 2 ultrasound scans. The first is an early scan, undertaken after 8 weeks gestation and used mainly for dating the pregnancy and confirming viability. The second ultrasound scan is undertaken between 18 to 20 weeks 6 days of pregnancy and screens for major structural anomalies in order that women are able to exercise informed choice about their pregnancy.

o   NHS Sickle Cell and Thalassaemia Screening Programme offers antenatal sickle cell and thalassaemia screening to all women (and couples) to facilitate informed decision-making.

4.4 NUH - Foetal anomalies

NUH provides specialist tertiary antenatal services for foetal medicine in the foeto-maternal medicine unit at the Queens Medical Centre (QMC) and the foetal care unit at City Hospital. The foetal medicine unit offers a range of non-invasive ultrasound as well as invasive karyotyping. When an abnormality is detected foetal medicine arrange referral to neonatal services if appropriate. There was a CQUIN for foetal medicine for 2013/14 which focused on the rapidity of obtaining a tertiary level foetal medicine opinion. The aim of this CQUIN was to achieve at least 90% of newly suspected /diagnosed lethal or major foetal abnormalities or other life-threatening foetal disorders referred to the foetal medicine centre seen within three working days. This target was achieved and is now embedding into service delivery.

4.5 NUH - Sickle cell and thalassemia service

The Sickle cell and thalassemia service is an integrated service that has an overview of antenatal, new-borns, children, young people, adults and families affected by sickle cell and thalassemia, as a carrier or diagnosed with the diseases. The overall aims of the service are to reduce sickle cell and thalassemia related mortality and morbidity and reduce hospital admissions, through improving community management.

Some of the service aims/outcomes are included below:

  • New born babies with a haemoglobin disorder diagnosed are reviewed within 12 weeks of birth and are seen a minimum of 4 times in 1st year of life, then ongoing according to requirement/age
  • New born babies who are healthy carriers of a haemoglobin disorder (from the new-born screening) are reviewed within 12 weeks of birth.
  • Personalised Care Plans in place, or underway, for 100% of clients.
  • Evidence of Adults with a diagnosed haemoglobin disorder receive a review of their care management a minimum of twice annually
  • An increase in access to the service and screening, by raising awareness in the community
  • An increase in access to the service and screening, by raising awareness with healthcare professionals

4.5 Primary Care services

A core offer to General Practitioners was developed in 2012 and part of this involved the implementation of named midwives for each practice and the development of bespoke communication routes for each practice. Where there are complications in pregnancy, vaccinations or medication required this is shared with a woman’s General Practice in the agreed way. It is recognised that these pathways require further improvement.

4.5.1 Flu vaccination

Midwives give information about the importance of having the flu vaccination during pregnancy at the maternity booking appointment and follow up with women at subsequent appointments. Women can access the vaccine free of charge from their GP any time during their pregnancy. Flu vaccine uptake by pregnant women in Nottingham during 2013/14 was 33.8%, significantly lower than the England average of 39.9%[ii].

4.6 Nottingham CityCare Partnership - Health Visiting Service

Nottingham CityCare Partnership provides the local health visiting service. Health visitors lead delivery of the HCP (0-5) and work in partnership with maternity services, local authority-provided or commissioned early years services, voluntary, private and independent services, primary and secondary care, schools, health improvement teams, Family Nurse Partnership (FNP) colleagues and children's social care services. The Health visiting services includes a one-one antenatal visit to all pregnant women at 28 weeks of pregnancy; data for Q1 2014/15 shows that 412 women received this contact. Based on the number of births per quarter in 2013, this suggests that suggests that approximately 38% of pregnant women received this contact.  Performance targets around this are Q1  25%, Q2  50%, Q3 75% and Q4 100%.

4.6.1 Healthy Start/vitamin D

The health visiting service also coordinates the Healthy Start/Vitamin D programme locally. From least 10 weeks of pregnancy, all women aged under 18 as well as pregnant women who get certain benefits or tax credits are eligible for free Healthy Start vitamins through the national programme. Additional funding is provided locally, to make this provision universal for all pregnant women. Women are informed of the programme by midwives, health visitors and Early Help services and vitamins are available in local community settings such as children’s centres. Accurate information on current uptake is not available, so the extent that pregnant women and their infants are protected against vitamin D deficiency is unknown.

4.7 Nottingham CityCare Partnership - Family Nurse Partnership

The Family Nurse Partnership (FNP) is an integral part of local services forming the targeted, intensive end of the prevention and early intervention pathway in pregnancy and the first 2 years of life. FNP is a one-to-one programme of education and empowerment, commenced in Nottingham in 2008. Intensive nursing support to teenage parents (to promote bonding, support breastfeeding, signposting to wider social support for parenting and promotion of healthy lifestyles, longer term educational attainment and reduced crime levels) has been shown to improve life outcomes for both mother and child. FNP is available to Nottingham residents who are under 19 years of age having their first baby or for mothers under 20 years who have additional health or social problems.

A randomised control trial on the FNP programme is underway.  The FNP programme in Nottingham is participating in a group work pilot which may be a more cost effective model for delivery.

The FNP in Nottingham City currently has 12 ½ full time equivalent (FTE) FNP practitioners who can each see around 25 clients: it is clear therefore that not all eligible women in Nottingham City can be seen on the programme. FNP currently reaches 40% of eligible women. Equity of access is unknown.

4.8 Small Steps Big Changes (SSBC)

SSBC is a 10 year Lottery funded programme to improve the lives and life chances of children. The programme focuses on pregnancy and the first three years of life and targets four Nottingham Wards (Aspley, Bulwell, St Ann’s and Arboretum). The programme has three developmental outcomes:

·         Communication and language

·         Nutrition

·         Social and emotional development

Aspects of the programme that are relevant to pregnancy include:

Baby Buddy – Baby Buddy is a free mobile phone app for parents and parents-to-be with personalised content that spans from conception right through to the first six months after birth. Baby Buddy has been created by child health charity Best Beginnings, and has been endorsed by the Department of Health and a number of Royal Colleges and professional organisations. 

Designed for young parents, Baby Buddy is every parents or parents-to-be personal baby expert who will guide them through their pregnancy and the first six months of their baby’s life. She will be their virtual friend who will support them on their emotional, physical and social journey through pregnancy and becoming a new parent.  Once a pregnant woman has created their Buddy, she will bring them daily personalised information about them and their baby.  The pregnant woman can ask her questions, use the app to remind them of appointments, find out about local services, set themselves goals, create a record of their pregnancy and their baby’s first months and watch a growing range of film clips in the video library.  

 SSBC has commissioned Best Beginnings to help embed ‘Baby Buddy’ across services in Nottingham, which has included training on ‘Baby Buddy’. SSBC has also started to work with health and early years providers to populate (and keep updated) the ‘Bump Around’ and ‘Baby Around’ section of the app which will help expectant families locate useful groups, activities and services.

Family Nurse Partnership – SSBC will be funding the employment of two Family Nurses which will extend the offer of the FNP in the four wards to all eligible young parents.

Pregnancy specific ‘cook and eat’ groups will be introduced.

Family Mentors - will be a new and innovative ‘peer workforce’ in Nottingham – not led by health professionals, but mums, dads, granddads and grandmas. All expectant families and families with new-born babies in Aspley and Bulwell will be offered a family mentor. Mentors will work alongside families, working in partnership with existing health and early years services.  The aim is to create trusted relationships between new parents, their families and family mentors so that together families and children can be supported to achieve better outcomes. The family mentors will be supported and guided by the SSBC programme and specialist teams, taking activities into family homes and delivering group sessions and interventions.   The family mentors for Bulwell and Aspley will be recruited from local families by Groundwork from August 2015 and will start to meet families in their wards by December 2015. The process of selecting an organisation to deliver the family mentors programme in St Ann’s and the Arboretum will commence early 2016.

In addition to the specific SSBC activities, it is also anticipated that the additional resource of the Family Mentor team will help raise awareness and uptake of some existing initiatives such as the Universal Vitamin D programme for pregnant women. SSBC has also led the review and refresh of Bump, Birth and Baby, an antenatal education programme which is described further below.

4.9 Maternal mental health services

The Healthy Child Programme specifies that all women’s mental health needs are assessed during pregnancy and emotional and psychological problems are addressed in the period up to 28 weeks and after 28 weeks gestation, through progressive support and also referral to appropriate specialist services as required. 

In Nottingham, women receive a thorough health and social care assessment at the midwifery booking appointment (usually by 12 weeks) and if required are referred to the specialist Perinatal Mental Health service which is commissioned to treat serious mental illness in pregnancy or to other appropriate services , such as IAPT services. The number of women receiving a perinatal mental health assessment at maternity booking and after 28 weeks gestation started to be collected in 2015/16; data will be reported in future updates of this chapter.

The NICE recommended Whooley questions have been implemented in 2015 and this assessment of emotional and mental health is revisited at the 28 week appointment as a minimum. The service also uses a perinatal mental health algorithm to assess mental health concerns which has been developed with the perinatal mental health services.

Whilst there is excellent local provision for women with serious mental illness, pathways to support women with less serious or emerging mental health issues need further development.

4.10 Maternal obesity services

A weight management in pregnancy pathway was developed in 2011/12 and incorporated into NUH maternal obesity guidelines (alongside mandatory midwifery training on obesity in pregnancy). Table 11 illustrates the pathway;

Table 11: Weight management in pregnancy pathway

 

Intervention/service

All pregnant women

o  Weighed and measured at booking appointment (8-12 weeks gestation)

o  Information and advice on nutrition and healthy weight given as part of the Healthy Child Programme.

o  Referral to Healthy Change

Pregnant

women with

 BMI ≥ 30

o  Referred to Slimming World

o  Additional midwife appointment at 24 weeks

Pregnant women with a BMI ≥ 40

o  Referral to an NUH Dietician

o  Additional midwife appointment at 24 weeks

           

Healthy Change - a telephone based lifestyle referral service commissioned by Nottingham City Council Public Health. Healthy Change supports adults with one or more Cardiovascular disease risk factor to set goals for behaviour change and supports them in accessing a range of other commissioned lifestyle prevention services. This service is accessible to pregnant women, although information on access by pregnant women is not collected/unknown.

Slimming World - offers a programme for pregnant women, which has been developed in conjunction with the Royal College of Midwives. Since 2010, it has been possible for community midwifes to refer Nottingham City registered patients and residents to Slimming World.  62 pregnant women accessed the service in 2014/15.  Using local estimates of maternal obesity prevalence in Nottingham, it is estimated therefore that just 9% of women with a BMI ≥ 30 - <40 accessed slimming world.

NUH have recently been successful in obtaining funding to deliver an evidenced based maternal obesity programme ‘Bumps and Beyond’. It is expected that this service will be operational from late in 2015 and will increase the proportion of obese pregnant women accessing weight management services.

4.11 Nottingham CityCare Partnership – New Leaf smoking cessation service

The New Leaf Nottingham City stop smoking service has two specialist pregnancy advisers who have a midwifery background.  The specialist advisers contact all pregnant smokers within two working days of receiving a referral unless they have specifically asked not to be contacted.

Midwives ascertain smoking status and record exhaled carbon monoxide (CO) levels at booking and at two further points in pregnancy.  Women identified as smokers, or those with a CO reading of 4 or above are referred to New Leaf on an opt-out basis through a well-established referral pathway.  Partners and family members can also be included in the referral.

Women are followed up pro-actively and receive intensive support throughout their pregnancy from the specialist team.  Consultations through an interpreter are offered if needed. Clients are also contacted post-natally (a time when relapse may occur); support to remain smoke free or to re-access the service is available.

575 pregnant women were referred to New Leaf during quarters 1-3 (2014/15) which accounts for approximately 17% of all maternities. This is very close to the proportion of women that are estimated to be smokers. Of those referred, 318 (55%) accessed New Leaf and 215 (67%) of these quit (4 weeks). This suggests that the opt-out referral system being used by midwifery is effective. It is unknown how many referrals to New Leaf come specifically via Health visiting and FNP, however overall referrals from CityCare Partnership are low. It also appears that the number of referrals from Nottingham City Council Early Help services is low.

New Leaf also provides training, updates and act as a specialist resource for midwives, student midwives, health visitors and other professionals working with pregnant women. During 2014/15, New Leaf trained 120 community midwives/maternity support workers and ten staff from Children's Centres.  In 2015/16, New Leaf is planning to deliver training to all Health Visitors/ Nursery Nurses, Family Nurses and children’s centre staff.

4.12 Antenatal classes

The Parent Education Department at NUH provides antenatal classes or workshops for women and their birth partner. A course of three workshops, each two hours in length, are offered at various times throughout the day and during evenings and weekends. The sessions are open to all ages, for couples or women/men on their own if preferred. The content covers active birth; management of pain and alternative births, infant feeding and early parenting. There are specialist sessions for multiple births.

The Department of Health have developed the Preparation for Birth and Beyond Framework, an approach to preparation for parenthood that reflects today’s context. The resource is designed to support multi-disciplinary working with new families. The themes in the framework cover the core aspects of pregnancy, birth, early child development and parenthood. Nottingham CityCare Partnership health visiting service have been providing preparation for Birth and Beyond for several years. However, delivery has been inconsistent across the City. SSBC have recently reviewed and updated the programme which has been renamed Bump, Birth and Baby. It is expected that the numbers of parents-to-be who access the programme will increase. The programme is designed to be delivered by a multidisciplinary team of midwives, health visitors and children’s centres, although this has not been progressed in Nottingham.

4.13 Early Help Services

Access to Early Help services provided through Children’s Centres is invaluable in ensuring women get the additional support they may need during this time. There are no specific programmes or interventions provided by Early Help services for pregnant women, however there is great potential for reaching and supporting pregnant women, especially those with complex social factors.  For example, Early Help Services are ideally suited to identify and refer pregnant women with low level anxiety and depression to services, although currently this is not happening in a systematic way.

The development of a more integrated and focused approach would help in supporting pregnant women with the greatest needs.


[i] PHE. PHE Alcohol Learning Resources – Audit C Tool. Available at: http://www.alcohollearningcentre.org.uk/Topics/Browse/BriefAdvice/?parent=4444&child=4898 [Accessed 29.05.2015]

[ii] Chimat (2015) - Infant mortality and Stillbirths profile. Available at:  http://atlas.chimat.org.uk/IAS/dataviews/report/fullpage?viewId=368&reportId=521&geoId=4&geoReportId=4597 . [Accessed 13.05.2015]

 

5. Evidence of what works (what we should be doing)

Back up to the contents

Evidence and guidance on maternity care and provision is provided in a number of national documents.

5.1 Midwifery 2020: Delivering Expectations

Midwifery 2020 sets out a vision for quality, cost-effective maternity services and highlights the importance of a midwife’s public health role. Midwifery 2020 makes a number of recommendations including, but not limited to the following:

  • Women must be able to choose to access midwives as the first point of contact
  • Midwives are the lead professional for women with no complications, and the coordinator of care for all women
  • Continuity of care: woman need a midwife they know and trust to coordinate their physical and emotional care through pregnancy and until the end of the postnatal period
  • Midwives should have a good knowledge of the health and social care needs of the local community; be well networked into the local health and social care system; and be proactive in identifying women at risk, and engaging with the woman, her family and other services as appropriate
  • The views and experiences of women and their partners are an important part of measuring quality and effective tools for collecting information about their experiences of care should be developed and widely used

5.2 Healthy Child programme (DH 2009)

The Healthy Child Programme (HCP): Pregnancy and the first five years of life (2009), originally developed in 2004 was refreshed in 2009 by the Department of Health. This is aimed at commissioners in health and local authorities as well as providers of services. There is great emphasis on the development of integrated services led by health professionals. The universal element of the HCP programme is provided for all families and additional preventive elements (progressive HCP) for children with additional risk factors.

The universal HCP includes the following:

  • Promotion of health and wellbeing, including health and social care risk assessment and screening
  • Preparation for parenthood, including provision of information, provision of group based antenatal education in the community and consideration of fathers concerns
  • Infant feeding
  • Maintaining infant health
  • Promoting sensitive parenting
  • Safe sleeping
  • Newborn screening and physical examination
  • Newborn immunisation
  • Assessing maternal mental health
  • Safeguarding
  • Identification of prolonged jaundice

The progressive HCP includes the following:

  • Ambivalence about pregnancy and low self-esteem
  • Depression and anxiety (including counselling) ad listening visits
  • Smoking cessation support
  • Obesity – support and advice for weight management
  • Breastfeeding
  • Additional support (often multi-agency) for the following women:
    • Young first time mums
    • Learning difficulties
    • Drug abuse
    • Alcohol abuse
    • Domestic violence
    • Serious mental illness
  • Babies with health or developmental problems
  • Lack of social support
  • Promotion of sensitive parenting
  • Targeted infant feeding support where there is risk of obesity

Healthy Child Programme Rapid Review[i]

The aim of this rapid review of the evidence was to synthesise relevant systematic review level evidence about ‘what works’ in key areas of public health for 0-5s, including pregnancy.

5.3 Conception to age 2

‘The age of opportunity, tackling the roots of disadvantage’ by the Wave Trust supports this framework and particularly the discussion on the emotional impact of parenthood.

5.4 NICE Guidance and Quality Standards

The following NICE guidance and Quality Standards provide recommendations relevant to maternity and pregnancy services.

PH11

Maternal and child nutrition

2008

PH26

Quitting smoking in pregnancy and following childbirth

2010

PH27

Weight management before, during and after pregnancy

2010

CG45

Antenatal and postnatal mental health

2007

CG62

Antenatal care

2010

QS4

Specialist neonatal care

2010

QS35

Hypertension in pregnancy

2013

QS37

Postnatal care

2013

QS46

Multiple pregnancy

2013

QS60

Induction of labour

2014

5.5 Department of Health Publications

The following Department of Health documents provide evidence based guidance.

Maternity Matters

2007

National Service Framework for Children, Young People and Maternity Services: Maternity services

2004

Making it better: For Mother and Baby

2007

Delivering Health Services Through Sure Start Children's Centres

2007

Midwifery 2020: Delivering Expectations

2010

5.6 Royal College for Obstetricians and Gynaecologists

Standards for Maternity Care (RCOG, 2008) sets out national standards for maternity care in this working party report, audit indicators and standards database.



[i] Public Health England (2015). Rapid Review to Update Evidence for the Healthy Child Programme 0–5. Available at: https://www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence [Accessed 18.09.15]

 

 

6. What is on the horizon?

Back up to the contents

Projected service use and outcomes in 3-5 years and 5-10 years

Limited data is available on which to judge projected service use. Provider contracts have specified that more detailed monitoring information will be provided to commissioners. SystmOne will help to facilitate this and enable measurement at each specified stage of the pathway to ensure compliance with NICE guidance. The number of maternities seems to have decreased slightly since 2011 although whether this downwards trend will continue is unknown. The current economic down turn would suggest that the demand for maternity services is unlikely to rise dramatically in the short to medium term. However, the local emphasis on early intervention and the Healthy Child Programme will mean additional support over and above the current provision will be required. Longer-term needs in this area are difficult to predict and depend on national and local social and economic conditions.

Emerging concerns and issues related to pregnancy outcomes which appear to be increasing include, but are not limited to, smoking in pregnancy, maternal obesity, number of women who cannot speak English and FGM. There is no indication that the proportion of pregnancies where there are complex social factors is likely to decrease in the foreseeable future; these complex pregnancies are therefore likely to continue to place pressures on local services and increase risks to maternal and infant health.

Commissioners and providers are working in partnership to implement a range of service improvements across the maternity pathway. 

7. Local views

Back up to the contents

The first results of the Friends and Family Test (FFT) for NHS-funded maternity services across England have been published (Figure x). The data comprises feedback from thousands of pregnant women and mothers of new-born babies who, since October 1, 2013, have been giving their views on the services they receive throughout their pregnancy.  They are asked whether they would recommend maternity services to their nearest and dearest based on their own experience. Their responses will build into the most comprehensive feedback exercise ever undertaken with pregnant women and involves 138 trusts and more than 200 maternity sites nationally.

Figure x:  England Comparative of Results of Friends and Family Test Questions  

 

7.2 Care Quality Commission (CQC)

The CQC have surveyed NUH maternity services as part of a series of surveys required of all Acute Trusts. Results are based on 150 inpatients who responded to the survey and gave birth at the Trust in February 2013. For the majority of indicators, CQC have categorised NUH’s results as ‘about the same’ as other Trusts.

In some areas NUH have been identified as scoring significantly better than average:

 

 

NUH

Average

Antenatal care: Not given a choice of where to have baby

6%

16%

During pregnancy: Did not have a midwifery telephone number

1%

3%

 

 

In a number of areas NUH have been identified as scoring significantly worse than average. These areas are:

 

 

NUH

Average

Antenatal check-ups: did not have enough time to ask questions

36%

27%

Labour and birth: Not treated with respect and dignity

23%

15%

Postnatal hospital care: not treated with kindness and understanding

44%

36%

Postnatal hospital care: toilets and bathrooms not clean

18%

10%

Feeding: Did not receive support and encouragement

49%

40%

Postnatal care at home: didn’t see the same midwife

79%

72%

Postnatal care at home: mothers not asked how they felt emotionally

9%

4%

Postnatal care at home: not given enough information about emotional changes that may be experienced

51%

42%

NUH were inspected by the Care Quality Commission (CQC) in in November 2013 under radical changes to inspections introduced. Overall, CQC reported that ‘maternity services were effective’. Patients felt welcomed and supported. At the time of inspection the trust had recently recruited 20 newly qualified midwives and CQC reported that some staff felt this might mean there was not adequate skills coverage. A number of points for improvement were raised within the CQC report; an action plan was put in place to address these and monitored by NUH via the quality route.

7.3 Partnership in Maternity (PIMS)

In addition to the above methods of engagement there is also a Partnership in Maternity (PIMS) group which aims to involve service users in decisions about maternity services.  After struggling to reinvigorate the group it was decided that PIMS would be reformed to become a group of professionals dedicated to collecting and reviewing service user feedback through a range of networks and bespoke engagement activities. This group was established in 2014/15.

7.4 Obesity in pregnancy

Maternity services staff conducted a focus group with eight women with a pre-pregnancy BMI of 30 or over in March 2012. Key themes identified were based on provision of information on obesity in pregnancy, cultural barriers during pregnancy and access to weight management support during pregnancy. This led to the development of the Bumps and Beyond pilot referenced previously in this document.

7.5 Migrant Women

A 2012 focus group by the Nottingham and Nottinghamshire Refugee Forum explored the health experiences and needs of refugees and asylum seekers in Nottingham and also highlighted that commissioners must stress the importance of using translation services.

6.5 Equality Impact Assessment (EIA)

An Equality Impact Assessment needs to be completed.

6.6 Continuity of carer

NICE states that women should be cared for by a named midwife throughout the pregnancy. Local information shows that women do not receive continuity of care by a named midwife:

  • Out of an audit of 200 women, 24% of women saw their allocated named midwife no more than twice in pregnancy and 3 women (6%) did not see their named midwife at all in their pregnancy.          
  • Engagement highlighted that women’s experience regarding continuity of carer was as follows:
  • Many women want continuity and to be able see the same midwife each time but were informed that this was not possible.
  • A number of comments were received and all related to the same subject; women are unhappy seeing a different midwife at each appointment.
  • 74% stated they had a named midwife throughout their pregnancy, 26% did not.
  • Of those who stated they had a named midwife. 62% saw them regularly (30% at every appointment; 32% at most appointments). 29% stated that they only saw their named midwife at a few appointments throughout their pregnancy; 7% hardly saw them and 4% did not see their named midwife at all.
  • 35% reported that they saw 1-2 midwives; 26% saw 2-4 midwives and 30% saw 3-5. 9% of women reported seeing 6 or more midwives throughout their pregnancy.

A further piece of engagement work was carried out scope what women felt would provide ‘continuity of carer’ and women agreed that having one or two defined midwives responsible for their care was important. In response to this a pilot has been initiated to re-establish the principle of midwives caring for a defined caseload.

What does this tell us?

8. Unmet needs and service gaps

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·         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.

9. Knowledge gaps

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•       Further data analysis and interpretation would be beneficial to better understand which groups of pregnant women are least likely to access maternity services early in pregnancy including by age, ethnicity and level of deprivation.

•       Maternal health of migrant women, asylum seekers and refugees requires a stronger focus as this is a growing population group. Language barriers coupled with lack of awareness of entitlement to free maternity care may be obstructing access for migrant women, particularly early access to maternity services. Further evidence needs to be gathered to assess and address the needs of this group. 

•       There is a lack of comprehensive data on maternal obesity in Nottingham.

•       There is a lack of understanding about which groups of pregnant smokers are least likely to access smoking cessation services and/or quit smoking during pregnancy; this is required to inform the future development of interventions and services.

•       A better understanding of the uptake of vitamin D amongst pregnant women is required.

•       Local data on alcohol consumption and substance misuse in pregnancy is lacking including the number of pregnant women accessing Recovery substance misuse services.

•       Knowledge about the number of pregnant women accessing specialist midwives (i.e. FGM, teenage pregnancy, homeless, substance misuse) would be beneficial in further understanding need.

•       A health equity audit of access to FNP would be beneficial in understanding whether there is equitable access for teenagers with the greatest need.

What should we do next?

10. Recommendations for consideration by commissioners

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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.

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.

Key contacts

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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

References

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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]

[1] 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]

[1]Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK (2014). Saving Lives: Improving Mother’s Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012. Available at: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf. [Accessed 18.09.15]

[1] Adapted from MBBRACE UK (2014). Saving Lives: Improving Mother’s Care Executive Summary. Available from: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Exec%20Summary.pdf [Accessed 10.04.15]

[1] National Institute of Health and Care Excellence (2010) CG110:   Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors. Available at: https://www.nice.org.uk/guidance/CG110/chapter/introduction. [Accessed 18.09.15]

[1] Standing Conference on Drug Misuse (SCODA) (1997) Working with Children and Families Affected by Parental Substance Misuse London: Local Government Association Publications

[1] Julien, R. (1995). A Primer of Drug Action: A Concise, Non-Technical Guide to the Actions, Uses, and Side Effects of Psychoactive Drugs. 7th Edition. New York: W.H. Freeman and Co

[1] Abel, E.L. (1998). Fetal Alcohol Syndrome: the American Paradox. Alcohol and Alcoholism, 33 (3), 195-201.

[1] Smith L, Savory J, Couves J, Burns E (2014). Alcohol consumption during pregnancy: cross-sectional survey. Midwifery Journal Dec;30(12):1173-8.

[1] Nottingham Insight (2015). Joint Strategic Needs Assessment (JSNA): Asylum seeker  Chapter

[1] Office for National Statistics (ONS) Quarterly 28 (2005). Available from

http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=15342. [Accessed 24.04.15]

[1] ONS, 2013. Births by Area of Usual Residence of Mother, UK, 2013. Available at: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-327582

[Accessed 17.07.15]

[1] ONS, Statistical bulletin: Live Births in England and Wales by Characteristics of Mother 1, 2013. Available at: http://ons.gov.uk/ons/rel/vsob1/characteristics-of-Mother-1--england-and-wales/2013/stb-characteristics-of-mother-1--2013.html. [Accessed 24.04.15]

[1] ONS, Statistical bulletin: Births in England and Wales by Characteristics of Birth 2, 2013. Available at: http://www.ons.gov.uk/ons/rel/vsob1/characteristics-of-birth-2--england-and-wales/2013/sb-characteristics-of-birth-2.html . [Accessed 24.04.15]

[1] National Institute for Health and Care Excellence (2011). PH27: Weight Management before, During and After Pregnancy. Available at:  https://www.nice.org.uk/guidance/ph27/resources/guidance-weight-management-before-during-and-after-pregnancy-pdf. [Accessed 24.05.14]

[1] Heslehurst, N., Rankin, J., Wilkinson, J. R., Summerbell, C. D. (2010) A nationally representative study of maternal obesity in England, UK: trends in incidence and demographic inequalities in 619 323 births, 1989–2007. International Journal of Obesity 34, 420–428

[1]National Institute for Health and Care Excellence (2014).  Vitamin D: increasing supplement use among at-risk groups. Available at: http://www.nice.org.uk/guidance/ph56/ [Accessed 24.04.2015]

[1] National Institute for Health and Care Excellence  (2008) CG62 – Antenatal Care. Available at: https://www.nice.org.uk/guidance/cg62. [Accessed 18.09.15]

[1] Blake M, Herrick K & Kelly Y. Health Survey for England 2002: Maternal and Infant Health. London.TSO, 2003.

[1] National Institute for Health and Care Excellence (2010). PH26 Quitting smoking in pregnancy and following childbirth.

[1] Fiona McAndrew, Jane Thompson, Lydia Fellows, Alice Large, Mark Speed and Mary J. Renfrew (2012) Infant feeding survey 2010. Available at: http://www.hscic.gov.uk/catalogue/PUB08694/Infant-Feeding-Survey-2010-Consolidated-Report.pdf. [Accessed 18.09.15]

[1] UNICEF (2013) Female Genital Mutilation/Cutting: a statistical overview and exploration of the dynamics of change. Available at: http://www.unicef.org/media/files/FGCM_Lo_res.pdf  . [Accessed  10.04.15]

[1] Health and social care information centre, Feb 2015. Female Genital Mutilation (FGM). Available at: www.hscic.gov.uk/fgm. [Accessed 10.04.2015]

[1] Department of Health (2014).  Abortion Statistics, England and Wales: 2013. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/319460/Abortion_Statistics__England_and_Wales_2013.pdf. [Accessed 10.04.2015]

[1]Chimat (2015) Service Snapshot-Infant Mortality and Stillbirths for Nottingham. Available from: http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=59&geoTypeId= [Accessed 27.04.2015]

[1] Department of Health. Annual Report of the Chief Medical Officer 2012, Our Children Deserve Better: Prevention Pays (Internet). London: DH; 2013 (cited 2014 Nov 11). Available from: https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2012-our-children-deserve-better-prevention-pays. [Accessed 10.04.15]

[1] NHS Choices (Internet). NHS. Stillbirth- causes; (reviewed 2013 Feb 22; cited 2014 Nov 11). Available from: http:// www.nhs.uk/Conditions/Stillbirth/Pages/Causes.aspx. [Accessed 10.04.15]

[1] Public Health England (2014). National Antenatal Infections Screening Monitoring: annual data tables. Available from: https://www.gov.uk/government/publications/national-antenatal-infections-screening-monitoring-annual-data-tables. [Accessed 10.04.15]

[1] Public Health England (2015). NHS Sickle Cell and Thalassaemia Screening Programme:

 Data Report 2013/14 Trends and performance analysis

[1] Chimat (2105). Service Snapshot – maternity. Available at: http://atlas.chimat.org.uk/IAS/profiles/profile?profileId=10&geoTypeId=[Accessed 18.09.15]

[1] Health and Social Care Information Centre, 2014. National Pregnancy in Diabetes Audit Report 2013 - East Midlands. Available at: http://www.hscic.gov.uk/searchcatalogue?productid=16021&q=%22National+Pregnancy+in+Diabetes+audit%22&sort=Relevance&size=10&page=1#top. [Accessed 17.07.15]

[1] Public Health England (2015). Public Health Outcomes framework data tool. Available at: http://www.phoutcomes.info/. [Accessed 18.09.15]

[1] Office for National Statistics Live births by country of birth of mother and area of usual residence 2012. Available at:

http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-320361 and 2001 to 2009: http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-39699. [Accessed 17.07.15]

[1] Nottingham Insight (2015) Joint Strategic Needs Assessment: Demography Chapter 2015

[1] Nottingham Crime and Drugs Partnership (2015). www.nottinghamcdp.com

[1] NICE (2010) Costing statement: Pregnancy and complex social factors. Available at: https://www.nice.org.uk/guidance/cg110/resources/cg110-pregnancy-and-complex-social-factors-costing-statement2. [Accessed 18.09.15]

[1] Plant ML, Miller P, Plant M (2005). The relationship between alcohol consumption and problem behaviours: Gender differences among British adults. Journal of Substance Use 10: 22–30

[1] NHS England 2015. Clinical Commissioning Group Outcome Indicator Set (CCG OIS). Available from: http://www.england.nhs.uk/ccg-ois/ [Accessed 13.05.2015]

[1] PHE. PHE Alcohol Learning Resources – Audit C Tool. Available at: http://www.alcohollearningcentre.org.uk/Topics/Browse/BriefAdvice/?parent=4444&child=4898 [Accessed 29.05.2015]

[1] Chimat (2015) - Infant mortality and Stillbirths profile. Available at:  http://atlas.chimat.org.uk/IAS/dataviews/report/fullpage?viewId=368&reportId=521&geoId=4&geoReportId=4597 . [Accessed 13.05.2015]

[1] Public Health England (2015). Rapid Review to Update Evidence for the Healthy Child Programme 0–5. Available at: https://www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence [Accessed 18.09.15]

Glossary