Healthy Pregnancy

Why Pregnancy is an important period

The first 1001 days of a child’s life represent a critical phase of heightened vulnerability, but also a window of enormous opportunity. The offering of advice and support to parents and carers provides an opportunity to help them to set the pattern for effective parenting and a nurturing environment during the early years of a child’s development.¹³

The circumstances and behaviours of parents/carers and the wider family before the baby is conceived, during pregnancy, and once the baby is born, can either have a positive or negative effect on their child’s development and future life chances. Babies born to parents with disadvantageous circumstances and unhealthy behaviours have an increased risk of low birth weight, early illness, and even early death. Intervening early will have an impact on a child’s resilience and their physical, mental, and socioeconomic outcomes in later life.

What is the local picture?

The rates of smoking at time of delivery in Central Bedfordshire are significantly higher (worse) when compared with local authorities in the same deprivation decile. However, they are significantly better compared to this decile for early access to maternity care.

The most recently compiled and published data is compared with other local authorities of similar deprivation, as of April 2021,¹⁴ unless otherwise stated.

Table 1 Healthy pregnancy in Central Bedfordshire

Significantly worse than comparator

Not significantly different than comparator

Significantly better than comparator

No IMD Decile Comparator

Central Bedfordshire’s overall score for deprivation (using the 2019 Index of Multiple Deprivation) relative to all other local authorities in England, puts it in the least deprived decile. Throughout this report, Central Bedfordshire’s performance is compared to other areas of similar deprivation where possible. For comparison to other local authorities of similar deprivation (IMD 2015), please refer to the reference.18 Table 1: Healthy pregnancy in Central Bedfordshire Sources: Public Health Outcomes Framework: CYP JSNA – Section 1 (IMD 2019): Available at: https://fingertips.phe.org.uk/ indicator-list/view/tWhIbQL5J0#page/0/gid/1/pat/10113/par/cat-113-10/ati/302/are/E06000056/iid/93085/age/1/ sex/2/cid/1/tbm/1 [Accessed 26 July 2021]. Public Health Outcomes Framework: CYP JSNA – Section 1 (IMD 2015): Public Health Outcomes Framework: CYP JSNA – Section 1 (IMD 2015): https://fingertips.phe.org.uk/indicator-list/ view/3bolzNZxDk#page/0/gid/1/pat/10039/par/cat-39-10/ati/102/are/E06000056/iid/93469/age/284/sex/4/cid/1/ tbm/1 [Accessed 14 January, 2021]. Public Health Outcome Framework. 2018. Public Health Profiles – PHE. [online] Available at: https://fingertips.phe.org.uk/ search/early%20access#page/0/gid/1/pat/10113/ati/302/are/E06000056/iid/93583/age/-1/sex/2/cid/1/tbm/1/pageoptions/car-do-0 [Accessed 12 August 2021]. Office of National Statistics. 2019. Conceptions in England and Wales – Office for National Statistics. [online] Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/datasets/ conceptionstatisticsenglandandwalesreferencetables [Accessed 12 August 2021]. *Local Authority Value – Percentage of pregnant women who have their booking appointment with a midwife with 10 completed weeks of their pregnancy

Infant mortality

There are approximately 3,363 live births in Central Bedfordshire each year and about 11 babies die each year before their first birthday. We have a similar infant mortality rate (3.4 per 1,000) as other local authorities in the same deprivation decile (3.2 deaths per 1,000 live births).¹⁹ During the period 1st April 2019 to 31st March 2020 across Bedfordshire and Luton, out of 47 child deaths reviewed by the Child Death Overview Panel (CDOP), modifiable factors were identified in 29% of cases (14/47). Although this is a decrease compared to previous years, the main modifiable factors identified remain similar: service provision (9 deaths), consanguinity (4 deaths), and maternal BMI (4 deaths). Unexpected deaths accounted for 19 out of 50 of the total deaths reported in 2019-20, and 35 deaths were of infants under 1 year of age.

The CDOP Action Plan for the coming year will focus on the following, through partnership working with all agencies:

• Maternal healthy weight
• Service-related modifiable factors
• Consanguinity
• Linking with other work streams, including Local Maternity Services, to share the wider learning, particularly from perinatal deaths where service modifiable factors have been identified

Early access to maternity care

Seeing a healthcare professional early in pregnancy is a key opportunity to assess a mother’s health and identify any risks within the family environment. Midwives provide advice and offer interventions to support a healthy pregnancy, including weight management during and after pregnancy and support to stop smoking.

Ensuring early access to a midwife, preferably by week 10 of pregnancy, will equip women with the knowledge and skills they need to modify the preventable risks to their pregnancy. Currently almost 7 out of 10 women access a midwife before 10 weeks of their pregnancy in Central Bedfordshire.

A Cochrane review²⁰ found that women who received midwife-led continuity of care were less likely to experience pre-term births or lose their baby in pregnancy or in the first month following birth. Specifically, they were:

• 16% less likely to lose their baby at any time
• 19% less likely to lose their baby before 24 weeks
• 24% less likely to experience pre-term birth

Equally, safety is not just about whether a baby lives or dies; safety for childbearing women, their partners and families also means emotional, psychological, and social safety. This holistic sense of safety is what pregnant women and their families receive through continuity models of care.

Locally, maternity services prioritise geographical areas where there are high levels of deprivation, and where women from ethnic minorities live. This targeted approach is proportionate to the level of disadvantage.

Ensuring that the care provided is personalised for all women, will help the focus to shift from what is important to the care provider to what is important to the mother and her family. Maternity services need to listen to women and their families, and ensure that their voices are heard. Women need to be equal partners in their care and their choices respected. Local maternity services are implementing a co-produced Personalised Maternity Journey document to help to facilitate this.

Local maternity services are in the process of implementing the ‘Saving Babies’ Lives Care Bundle’²¹ – a set of guidelines for reducing stillbirth. Risk assessments need to be undertaken throughout pregnancy and improvements made to monitoring fetal wellbeing. Women with complex pregnancies need to have a named obstetrician who has early involvement and input into management plans.

Smoking in pregnancy

Smoking is the single most important risk factor in pregnancy; maternal smoking during pregnancy is a cause of ill health for both mother and baby, and infant deaths.

Smoking increases the risk of complications in pregnancy and of the child developing a number of conditions later in life including:

• Premature birth
• Low birth weight
• Problems of the ear, nose and throat
• Respiratory conditions
• Obesity
• Diabetes

Babies from less affluent backgrounds are more likely to be born to mothers who smoke, and this is contributing to the gap in health inequalities. Children born to parents who smoke are also more likely to become smokers themselves, which further perpetuates this inequality.²²

Pregnant women and their partners are referred to the local Stop Smoking Service for specialist support
www.thestopsmokingservice.co.uk.

The stop smoking referral system is an opt-out system for pregnant women and in 2019-2020, it is estimated that 118 pregnant women across Central Bedfordshire were referred to the service for support. Early identification and effective referral pathways for pregnant women who smoke and their partners to the Stop Smoking Service is vital for producing the best outcomes. In 2019-20, 8.2% of women in Central Bedfordshire were still smoking at time of delivery and around one in seven babies (13.7%) live in a household with a smoker.²³

The COVID-19 pandemic has had an impact on the number of referrals in 2020-21, which have decreased on the year before. A virtual training programme has been rolled out to all midwifery staff to ensure that pregnant women who smoke continue to be referred into the service at the earliest possible opportunity.

Maternal obesity

Maternal obesity is defined as having a Body Mass Index (BMI) of 30kg/m2 or more at the first antenatal appointment. Being obese during pregnancy increases the health risks for both the mother and child during and after pregnancy.²⁴

Pregnant women who are obese are at increased risk of:

• Having a stillbirth
• Raised blood pressure and pre-eclampsia
• Having a large baby or ill baby who needs monitoring
• Developing gestational diabetes
• Having a blood clot in the legs (DVT)
• Needing a caesarean section

Maternal obesity has also been linked to chronic health conditions in children (including asthma and diabetes), and childhood excess weight and obesity. Amongst all women in England of childbearing age (16-44 years), around half are overweight or obese (BMI greater than or equal to 30).²⁵

During pregnancy, diet and exercise interventions can help to reduce the amount of weight gain. Advice on how to eat healthily and keep physically active is offered as part of routine antenatal and postnatal care by midwives and health visitors. Pregnant women are referred to the local weight management services. In Central Bedfordshire, the weight management programme is offered by MoreLife.

Teenage parents

In 2019, there were 65 under-18 conceptions in Central Bedfordshire. From 2014 to 2018 the rate of conceptions in under 18s has been significantly higher than local authorities in the same deprivation decile, and although there is no deprivation decile benchmark available currently, this has decreased slightly from 14.5 per 1,000 (2018) to 14.1 per 1,000 (2019).²⁶ Supporting young people who choose to become parents is crucial to improve outcomes for both the parents and child. Evidence shows that poorer outcomes are not inevitable, if early, co-ordinated and sustained support is put in place, which is trusted by young parents and focused on building their skills, confidence and aspirations. This requires a range of support services, co-ordinated by a lead professional.

Mothers under 20 years of age are:

• 3 times more likely to smoke throughout pregnancy
• 50% less likely to breastfeed at 6–8 weeks
• At higher risk of postnatal depression and poor mental health for up to three years after the birth
• 22% more likely to be living in poverty at age 30 and less likely to be employed or living with a partner
• 20% more likely to have no qualifications at age 30. Of all young people who are not in education, employment or training, 12% are teenage mothers

Babies born to young women under 20 have a:

• 30% higher risk of a low birth weight
• 60% higher risk of infant mortality
• 63% higher risk of experiencing child poverty

Young fathers are more likely to have poor education and have a greater risk of being unemployed in adult life.

To support young parents in Central Bedfordshire, there is a local Support Pathway for Parents under 20. The pathway offers young parents a range of support to improve outcomes for themselves, their partner, and their child. The Support Pathway begins from the very first booking appointment with the midwife where young parents complete a consented referral form for further support.

Maternal mental health

The effects of poor mental health go beyond the parent. During the perinatal period (pregnancy and the first year following birth), poor maternal mental health has important consequences on the infant’s mental health, their general health, and their emotional, behavioural and learning outcomes. Women are at risk of developing a first episode of mental illness during this time, with more than 1 in 10 women affected.²⁹

Mental health issues can affect the mother’s ability to bond with her baby and affect the baby’s ability to
develop a secure attachment. Knowing the risk factors and the symptoms can help with early identification, and in providing timely support and treatment to minimise the impact on the mother, child and family.

Maternal depression is also the strongest predictor of paternal depression, which is estimated at 4% during the first year after birth.³⁰

Key government investment into local perinatal mental health services has supported the identification of gaps in current care provision and led to the development of integrated pathways of care. This has resulted in an increase in specialist mental health care from 12-24 months, improved access to psychological therapies and mental health checks for partners. Furthermore, the co-production of maternity outreach services is in development for women with associated loss and trauma. This will include birth trauma, post-traumatic stress disorder (PTSD) following perinatal loss, parental separation, and severe fear of childbirth (tokophobia)

Pregnancy can alter the body’s immune system and response to viral infections, occasionally causing more severe symptoms. This may be the same for COVID-19, but there is currently no evidence that pregnant women have an increased risk of severe disease, or that there is a risk to new-born babies.

However, in response to the data which indicates that ethnic minority communities are disproportionally affected by COVID-19. Local maternity services have implemented the challenge set by the National Chief Midwifery Officer, Professor Jaqueline Dunkley-Bent, to implement four key areas to help to address these inequalities:

1. Co-produced operational policy and implementation to manage the risks of COVID-19 for ethnic minorities and at-risk pregnant women
2. Co-produced tailored communication to reassure ethnic minority women to seek help if they have any concerns
3. Routine discussion of vitamins, supplements and nutrition in pregnancy
4. Record data on maternity information systems

During the first wave of COVID-19 in early 2020, there were changes to the antenatal pathway which included the replacement of some face-to-face consultations with virtual consultations. This was to assist women practising social distancing measures and reduce the risk of transmission between women, staff and other clinic/hospital visitors. Greater attendance by parents has been noted for some virtual health visitor appointments.

Those appointments requiring face-to-face antenatal care were provided in children and family centres,
encouraging collaborative working across services. A local co-produced ‘stepping stones’ pictogram was
published widely on social media to help families to navigate the changes to services made during the
COVID-19 pandemic.

Some antenatal education classes are still being carried out virtually, and a challenging consequence of the changes to antenatal services has been the increase in loneliness and isolation, with vulnerable mothers being able to mask their mental health problems. Maternity services and staff have also highlighted increased maternal anxiety due to changes in how antenatal support and education are delivered.³¹

1. Promote early access to maternity care (by 10 weeks) and monitor where mothers are presenting later to identify if there are any additional needs.
2. Embed a ‘Think Family’ approach to identify and support needs, and ensure services encompass partners and significant adults within the family.
3. Transform and improve local maternity services in line with Better Births³² drivers; ensure services continue to be co-produced locally, and that maternity safety champions are represented at trust board level.

1. Roll-out ‘Continuity of Carer’ for all women, to address many of the pre-existing health inequalities – so that more women are less likely to experience preterm births, lose their baby in pregnancy or in the first month following birth.
2. All services throughout the maternity journey should listen to women and their partners, ensure that their voices are heard, and respect their informed choices by personalising their care.
3. Improve information sharing systems between maternity and health visiting services so that 100% pregnant women are referred to the health visiting service by 24 weeks, to ensure prompt access to the full Healthy Child Programme.
4. Develop and co-produce maternal mental health services associated with grief, loss and trauma to meet the current gap in provision.
5. Review the effectiveness and impact of the parental mental health pathway – with a particular focus on ethnic minority families – to address mental illness during the perinatal period.
6. Develop and monitor a training programme to improve the skills of service providers in order to provide a more effective tailored approach to support women in reducing dependence on tobacco.
7. Ensure effective measurement and recording of BMI, and referral to appropriate weight management services – as per the Maternal Obesity Pathway – in both the antenatal and postnatal periods.

References

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