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Early access to antenatal care

Introduction

A care pathway describes what a person's journey of care should looks like; what care they should receive, when they should receive it and when they should be referred for additional care and support. The pathway will outline routine care which all people should receive, and there may be additional pathways which only some people will go through, in order to provide for any additional needs. Whatever the individual journey, the use of a care pathway should result in the same standard of care being provided to each individual.

The antenatal care pathway (NICE, 2016) describes the journey of care which should be provided to all pregnant women. Additional pathways are outlined for women who have pre-existing health conditions, or more complicated pregnancies.

The antenatal pathway is a key time for screening for, and prevention of, conditions in the unborn child which could lead to poor health outcomes. It is also essential to maximise the health of the mother in pregnancy, which, as a recent global trial has shown, is a key indicator of healthy birth outcomes for the child (Bhutta and Kennedy, 2014).

The National Antenatal Screening Programme provides a timeline for screening during pregnancy, which includes the following:

  • Pre-conception eye screening for women with type 1 or 2 diabetes and again at 28 weeks;
  • Midwives working within screening teams undertake blood tests to detect Sickle cell disease and Thalassaemia by 10 weeks;
  • Blood tests and scans will be offered 12 weeks for trisomy conditions (covering Down's, Edward's and Patau's Syndromes) - blood tests are not offered at 20 weeks;
  • Screening for infectious disease, if declined at the beginning, should be offered again at 16 weeks
  • Further screening of the new born child is done at 5 days of age and is recommended at days 5 - 8 (day 5 is best), as part of the newborn blood spot test;
  • A physical examination within 72 hours of the birth

The maternity care that every woman should receive as part of the antenatal care pathway is listed in the maternity section. The Healthy Child Programme is a programme of health and social care that should be received by all children age 0 to 5 years. It includes a detailed schedule for care during pregnancy. This schedule requires that the mother receives the following checks in pregnancy:

  • A full health and social care assessment of needs, risks and choices by 12 weeks of pregnancy by a midwife or maternity healthcare professional;
  • Notification to the child health programme team of prospective parents requiring additional early intervention and prevention;
  • Routine antenatal care and screening for maternal infections, rubella susceptibility, blood disorders and foetal anomalies;
  • Health and lifestyle advice to include diet, weight control, physical activity, smoking, stress in pregnancy, alcohol, drug intake, etc.;
  • Distribution of The Pregnancy Book to first-time parents; access to written/online information about, and preparation for, childbirth and parenting; distribution of antenatal screening leaflet;
  • Discussion on benefits of breastfeeding with prospective parents, and risks of not breastfeeding;
  • Introduction to resources, including children's centres, Family Information Services, primary healthcare teams, and benefits and housing advice;
  • Support for families whose first language is not English.

In addition, preparation for parenthood should begin early in pregnancy and include:

  • Information on services and choices, maternal/paternal rights and benefits, use of prescription drugs during pregnancy, dietary considerations, travel safety, maternal self-care, etc.
  • Social support using group-based antenatal classes in community or healthcare settings that respond to the priorities of parents and cover:
    • the transition to parenthood (particularly for first-time parents); relationship issues and preparation for new roles and responsibilities; the parent-infant relationship; problem-solving skills (based on programmes such as Preparation for Parenting, First Steps in Parenting, One Plus One);
    • the specific concerns of fathers, including advice about supporting their partner during pregnancy and labour, care of infants, emotional and practical preparation for fatherhood (particularly for first-time fathers);
    • discussion on breastfeeding using interactive group work and/or peer support programmes; and standard health promotion.

In addition, extra support should be offered to vulnerable women at risk of having low birth weight babies. The Family Nurse Partnership offers additional support for young parents aged 19 or younger.

What do we know?

The Oxford Academic Health Sciences Network has identified two key areas for collaborative work: reducing stillbirths and preterm births

The clinical projects underway include:

  • Universal availability of screening results that can be used to screen for stillbirth
  • Universal fibronectin usage in threatened preterm labour
  • Universal prenatal diagnosis of placenta accrete (AIP)
  • Automated image quality analysis for anomaly scanning
  • Development of robotic remote ultrasound scanning
  • Early diagnosis of pre-eclampsia
  • Rationalisation of preterm labour services
  • Screening for preterm labour

In terms of prevention, the work of the Family Nurse Partnership helps to ensure good outcomes for vulnerable young women in pregnancy. Smoking cessation services are currently supporting pregnant women to quit smoking. However, they cannot currently validate the number of quitters, as they do not currently have access to carbon monoxide monitors in the hospital. These test a person's breathe for carbon monoxide, which is present in tobacco smoke.

Facts, Figures, Trends

Late access to screening and support in the antenatal pathway is a risk for poor birth outcomes and of being born before full term, alongside concealed pregnancies, which can highlight safeguarding concerns.

NHS England collects data from maternity service providers about the number of women who have accessed maternity services by the recommended 12 weeks and 6 days of pregnancy. In order to do this, the service provider counts the number of pregnant women who access services within this timeframe and the number of pregnant women who access services at any point in time. This is then compared to the number of women who give birth six months later. This gives an estimation of the percentage of women who access services within the recommended timeframe. The data is broken down by service provider and by the Clinical Commissioning Group (CCG) with which the mother is registered for GP services. Recent data for Berkshire is consistently returning figures of near to or above 100% of mothers accessing services within the recommended timeframe. (Figures can be above 100%, as maternity data is taken from two quarters after the service access data and does not refer to the same cohort of women. Additionally, the mothers giving birth may be lower than the number of mothers having an assessment due to those having terminations, suffering miscarriage or transferring to another hospital. Mothers may also be double-counted if they choose to have assessments at more than one hospital.)

Low birth weight (when a baby weighs less than 2,500g) is a key indicator of health inequalities. The Public Health Outcomes Framework reports the number of babies of at least 37 completed week's gestation born at a low birth weight.

Figure 1: Low birth weight as a percentage of term babies

image1

Source: Public Health Outcomes Framework

Table 1: Low birth weight as a percentage of term babies

 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Reading

4.6

3.3

3.3

3.0

2.4

3.4

3.5

2.8

2.5

3.0

 

South East

2.5

2.5

2.5

2.3

2.5

2.4

2.3

2.3

2.4

2.4

 

England

3.1

3.0

2.9

2.9

2.9

2.9

2.8

2.8

2.8

2.9

 

Source: Public Health Outcomes Framework

The percentage rate of low birth weight in Reading (3.0%) was not significantly different to England (2.9%) in 2014, although the rate for the South East region was somewhat lower, at 2.4%. The rates for England and the South East region have remained fairly static since 2005 (see Figure 1 and Table 1 above). Over the last 10 years, the rates for Reading have fluctuated from a high of 4.6% in 2005 to a low of 2.4% in 2009. It is difficult to attribute these fluctuations to one particular issue, but lifestyle choices by pregnant women around diet, weight control, physical activity, smoking, alcohol, drug intake, etc. could all be a factor in contributing to low weight babies at delivery. The latest 3 years' worth of data show that Reading has been close to, or below, the England average, which is encouraging. Continued work with mothers to be, in terms of supporting them to lead healthier lifestyles during pregnancy, should help to reduce further the numbers of babies born with a low birth weight.

A Thames Valley Still Birth Audit showed that for the 3 year period 2011-13 the average rates across the UK were around 4.9 per 1,000 births. In the South East region the rates were around 4.6 per 1,000 births. Rates have been further broken down by Clinical Commissioning Group area; for South Reading CCG, the rates were around 6.1 per 1,000 births and for North & West Reading, the rates were around 3.9 per 1,000 births. Caution should be observed as the numbers used in the audit were small so may not be a reliable indicator of differences. Other risk factors for still birth and infant death include: maternal age, socioeconomic position, multiple birth, and influenza (NHS England, 2014).

Stillbirth rates are highest for mothers aged under 20 or over 40. Smoking in pregnancy doubles the risk of stillbirth. Figure 2 below shows the latest annual trend data for Smoking Status at Time of Delivery (SSATOD). As shown, 7.4% of women in Reading were smoking at time of delivery in 2014/15. If we apply this to the number of women resident in Reading giving birth in 2014/15 (3,098), we can estimate that more than 200 of these women were smokers. Whilst England has shown a consistent downward trend since 2010/11, the trend in Reading has remained fairly static, with no significant reductions, over the same period.

Figure 2: Percentage of mothers smoking at time of delivery (SATOD), England and Reading, 2010/11 to 2014/15

image2

Source: Health and Social Care Information Centre.

The chart above clearly shows that rates for Reading have consistently been lower than those for England, however, the gap is reducing. Action is needed locally to create a consistent downward trend, so that fewer pregnant women smoke during pregnancy, up to birth and beyond.

Being overweight or obese may double the odds of stillbirth, and the risk increases as BMI increases. Similarly, multiple births tend to have lower birth-weights than singletons and are associated with a higher risk of stillbirth. There is also evidence that having flu during pregnancy may be associated with premature birth and smaller birth size and weight.

National & Local Strategies (Current best practices)          

Current best practice is based on NICE guidance CG110 (NICE, 2008) which describes the additional care needed for vulnerable women over and above the standard antenatal pathway, and NICE guidance on antenatal care CG62 (NICE, 2008). This contains partial updates for PH56 Vitamin D: increasing supplement use among at-risk groups and CG192 Antenatal and postnatal mental health.

The evidence base for the pregnancy and the first five years can be found in the Healthy Child Programme (DoH, 2009) and in the recently published evidence based review of the Health Child Programme: rapid review (DoH, 2015).

Examples of good practice elsewhere suggest that the most effective interventions to reduce smoking in pregnancy  are:

  • Psychosocial interventions, which can increase the proportion of women who stop smoking in late pregnancy, and reduce low birth weight and preterm births;
  • Incentive-based interventions show the largest effect, although caution is needed as they were only effective with intensive delivery and studies of effectiveness were in the US;
  • Financial incentives to promote non-smoking during pregnancy show promise, and may meet the treatment needs of socio-economically disadvantaged women and heavy smokers.

Localised clinical interventions for the reduction of still births are as set out in the Thames Valley clinical network plan:

  • There is a need for further education of primary care and midwifery staff on features of pre-conception and early pregnancy care highlighting the need for things such as aspirin, high dose folic acid, good diabetic care etc.;
  • The measurement of fundal height should be standardised across Thames Valley and recorded at each antenatal visit;
  • Each Trust should consider whether women who are having serial scans should have either additional scans or the timing of routine scans altered such that late pregnancy is covered;
  • Every professional should be aware of the need for good communication and ensure a full history is available where a woman is moving between providers;
  • Each discharge summary after pregnancy should contain specific advice about the need for any special measures in any subsequent pregnancy, and should be provided to the mother;
  • Each Trust should examine how post mortem consent is sought, and by whom, in order to improve the uptake of post mortem after stillbirth.

What is this telling us?

It should be ensured that all women access the antenatal care pathway, by the recommended stage of pregnancy in order to offer every woman the same standard of care and support. This will make certain that the vital opportunity for screening and optimisation of a mother's health during pregnancy is taken. It will provide opportunity for information sharing for all parents, and for specialist support to be given to those who need it.

Key areas of work are centred on working collaboratively in order to reduce still births and preterm births. There are inequalities in the timeliness of accessing the antenatal care pathways, and the occurrence of babies being born with a low birth weight or being still born. Tackling these inequalities is key to ensuring that all women are offered the best standard of care and that their babies are offered the best start in life.

What are the key inequalities?

NICE Guidance CG 110 (NICE, 2010) for women who have complex social risk factors is clear; the vulnerabilities most commonly found with poor or delayed access to the antenatal pathway are in women who;

  • speak English as a second language
  • are substance misusers
  • are new entrants or asylum seekers
  • who are suffering from domestic abuse

Are first time mothers under the age of 20 years.

What are the unmet needs/ service gaps?

  • There is as yet no widespread antenatal prevention programme in place or a consistent offer of cervical screening within our main hospital providers across the Thames Valley.
  • There is a gap in population wide provision of healthy weight and smoking cessation advice to pregnant women specifically, although they can access existing general services which are currently available.

 

This section links to the following sections in the JSNA:

Maternity

Perinatal Mental Health

Infant Mortality

Smoking in Pregnancy

References

Bhutta, A, Kennedy, S.H, et al. (2014). 'The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project'. The Lancet [Online]. Available at: http://www.thelancet.com/journals/landia/article/PIIS2213-8587(14)70121-4/abstract . [Accessed: 10/03/2016].

Department of Health (2009). Healthy Child Programme: Pregnancy and the First 5 Years of Life. [Online]. Available at: https://www.gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life. [Accessed: 10/03/16].

Department of Health (2015). Healthy Child Programme: rapid review to update evidence. [Online]. Available at: https://www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence. [Accessed: 10/03/16].

National Institute for Care and Health Excellence (2008). Antenatal Care for Uncomplicated Pregnancies. [Online]. Available at: https://www.nice.org.uk/guidance/cg62. [Accessed: 10/03/16].

National Institute for Care and Health Excellence (2014). Antenatal and postnatal mental health: clinical management and service guidance. [Online]. Available at: http://www.nice.org.uk/guidance/cg192. [Accessed: 10/03/16].

National Institute for Care and Health Excellence (2014). Vitamin D: increasing supplement use in at-risk groups. [Online]. Available at: http://www.nice.org.uk/guidance/ph56. [Accessed: 10/03/16].

National Institute for Care and Health Excellence (2016). Antenatal Care Pathway. [Online]. Available at: http://pathways.nice.org.uk/pathways/antenatal-care. [Accessed: 10/03/16].

National Institute for Care and Health Excellence (2016). Pregnant Women with Complex Social Factors Pathway (CG110). [Online]. Available at: http://pathways.nice.org.uk/pathways/pregnancy-and-complex-social-factors. [Accessed: 10/03/16].

NHS England (2014). Draft report Thames Valley Still Birth Audit 2014. [Online]. Available at: http://tvscn.nhs.uk/wp-content/uploads/2015/03/Final-Thames-Valley-SCN-Children-and-Maternity-Still-birth-Report-v-3.pdf. [Accessed: 10/03/16].

NHS England (2016). Maternity and Breastfeeding. [Online]. Available at: https://www.england.nhs.uk/statistics/statistical-work-areas/maternity-and-breastfeeding/. [Accessed: 10/03/16].

Public Health England (2016). Antenatal and newborn screening timeline. [Online]. Available at: http://cpd.screening.nhs.uk/timeline. [Accessed: 10/03/16].

University of Oxford (2015). Intergrowth-21st Study and Interbio-21st Study presentation. [Online]. Available at: http://www.oxfordahsn.org/wp-content/uploads/2014/11/Stephen-Kennedy-Healthy-Mothers-Healthy-Babies.pdf. [Accessed: 10/03/16].

Appendices

Family Nurse Partnership, 2015. [Online]. Available at: http://fnp.nhs.uk/. [Accessed: 10/03/16].

 

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