New JSNA: This is the test site for the new Joint Strategic Needs Assessment

Maternity

Introduction

Women from Reading mainly access maternity services from Royal Berkshire NHS Foundation Trust.

Antenatal screening programmes are offered to pregnant women to test for certain health issues that could be present in their unborn children. The tests offered help to detect:

  • Hepatitis B, HIV, syphilis and immunity to rubella
  • Down's syndrome, Patau's syndrome and Edward's syndrome
  • Sickle cell disease and thalassemia
  • Physical abnormalities

The maternity care that every woman should receive as part of the antenatal care pathway is listed below. 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.

What do we know?

During 2013/14 data submissions to NHS England recording the number of women accessing maternity services by 12 weeks and 6 days of pregnancy were insufficient to calculate an England total. In 2012/13 the percentage was 94.2%, an increase on the 2011/12 figure of 92.9%.

There are six National Key Performance Indicators (KPI's) for antenatal screening and a further 5 newborn screening KPIs. The latest data is for Q2 2014/15. Nationally 7 of the total 11 KPIs reached the 'acceptable' target level. Those which didn't were for Down's Syndrome Screening (0.4% away from target), New Born Hearing Test within 4 weeks of referral (4.7% away from target), New Born Bloodspot Screening (2.2% away from target), and avoidable Bloodspot repeat tests (0.9% away from target). (Note: Refer to Antenatal & Newborn Screening section for local data).

Facts, Figures, Trends

During 2013/14, 90.2% of pregnant women from NHS North & West Reading CCG were accessing maternity services by 12 weeks and 6 days of pregnancy. 89% of pregnant women from NHS South Reading CCG were accessing maternity services by 12 weeks and 6 days of pregnancy (data met the validation criteria).

Births

The number of births will always be higher than maternities, due to multiple births. The general fertility rate (GFR) is 67.8/1000 women aged 15-44. Number of live births in 2014 in Reading was 2572, a decrease of 50 from 2013. There was an overall reduction in the number of live births at RBH between 2011/12 (5963) and 2014/15 (5681).

In 2014, 2.6% of births in Reading were home births, compared to 2.3% across England (ONS, 2015). The fertility of women under twenty years of age has fallen by 10%, and indeed has been falling across Europe steadily for the last ten years. Fertility rates in the over 35s have, in contrast, risen but only by about 2.5%. Teenage conceptions have, historically been reported to be higher in this part of the Thames Valley than the National average, but the number who are still of statutory school age who actually continue with their pregnancy is small, typically around 10-12. In 2014 there were just four girls who became mothers. Locally, 265 young women under the age of 20 had babies in the last year, a fall of 10% on 2013, and nearly 30% fewer than in 2012.   

Risk Factors for Complex Births

Factors that increase the complexity of maternity care include:

  • Age - In 2013, just over 900 women were over 35 years of age at booking at Royal Berkshire Hospital (RBH). In 2010 there were 580 from Reading. They are at greater risk of complications and this impacts on the prenatal screening and diagnostic services, and is associated with an increased prevalence of comorbidities which impact on all aspects of antenatal and intrapartum care.
  • Obesity - If a pregnant woman is obese this will have a greater negative influence on their health and the health of their unborn baby. In 2011/12 18% of mothers booking were obese (Body Mass Index of over 30kg/m2), an increase from 15% in 2007 (source Berkshire West Maternity Needs assessment).
  • Smoking - Smoking Status at Time of Delivery (SATOD) is recorded and in 2014/15 7.4% of maternities in Reading had smoking recorded, which compares favourably to the England rate of 11.4%. Nationally, in 2013/14, 47% (n = 9,385) of pregnant women setting a quit date successfully quit.
  • Ethnicity and deprivation - Office of National Statistics (ONS) data shows that mothers with a Black or Asian background have higher rates of neonatal and infant deaths, and babies with African, Asian and Caribbean ethnicity also having higher rates of low birth weights.
  • Long Term Conditions - The Royal Berkshire Hospital is reporting higher number of maternity cases with diabetes and heart disease (RBH is the only District General Hospital in Thames Valley to have a dedicated cardiac antenatal clinic: every other unit refers to a teaching centre) which leads to more complex maternity care
  • Caesarean section rates - National Institute for Health and Clinical Excellence (NICE, 2011) have published guidelines for caesarean sections - and whilst there is not a defined optimal percentage the Royal Berkshire Hospital caesarean section rate is around 28% with national averages around 25%.

 

Percentage  of  deliveries  conducted  by  caesarean  section  at  maternity  units serving the Berkshire population  - 2013/14

Royal Berkshire Hospital

28.0%

Wexham Park

29.0%

Great Western

26.4%

Frimley Park

24.4%

Basingstoke and North Hampshire

24.9%

 

National & Local Strategies (Current best practices)

Quality and safety are essential in the delivery of maternity care to ensure we get the best outcomes for babies and mothers. There is a strong national framework for maternity services with significant national policy and guidance. The Royal College of Obstetricians and Gynaecologists have published clinical standards. The NHS Litigation Authority has published standards for  risk  management  and  National  Institute  for  Health and  Clinical  Excellence (NICE) have published a wide range of clinical guidance and pathways that should be followed to ensure the best care is available during and after pregnancy.

National policies on maternity particularly emphasize the rights of mothers to choose not only location of birth but also the style of birth (within clinical indications).

For mothers registered with South Reading CCG / North and West CCG most births occur in the Royal Berkshire Hospital. However, a small percentage does choose to have their babies at Basingstoke and Oxford hospitals.

Mothers should be able to choose with clinical support the options of home births, midwife led births or consultant led births. All of these options are now available within the Royal Berkshire Hospitals; however as mentioned previously caesarean section rates are higher than the national average as are home births.

What is this telling us?

Locally there is a pressure on maternity capacity and the local commissioners are developing actions to ensure that the accessibility, quality and safety of the services are protected and developed in a cost effective way. Acting together the Berkshire West CCGs have developed a 2014/15 action plan that offers:

  • Accessible, safe, high quality, supportive maternity services which meet the needs of our local population and ensure the most effective use of NHS resources
  • A women-led service that provides an excellent maternity experience for women and their partners
  • Women-centred maternity services that provide choice, continuity and confidence for women, designed to meet their individual needs of and those of their babies.

What are the key inequalities?

Antenatal clinics are offered by royal Berkshire Foundation NHS Trust across Berkshire. Whilst clinics are offered on three sites, access to a sonographer to scan whilst the mother is in clinic is limited to the Royal Berkshire Hospital site: at Wokingham there is neither machine nor personnel. Whilst obstetricians can scan, they are not all trained to the 'intermediate level' and scanning will add up to twenty minutes to an appointment where a sonographer is not available, and so cannot be 'slotted in' without impacting on other women's appointments and waiting times once they arrive.

Home births take two midwives into the home to deliver a healthy low risk mother of a healthy baby, at a time when the staff numbers make it harder to maintain safe levels in the hospital (on both the midwifery led birth centre (Rushey) and the main delivery suite).

This section links to the following sections in the JSNA:

Antenatal & Newborn Screening

Early access to antenatal care

Birth predictions over coming years

Infant Mortality

References

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

HSC Public Health Agency, 2015. The Pregnancy Book. [Online]. Available at: http://www.publichealth.hscni.net/publications/pregnancy-book-0

National Institute for Health and Care Excellence, 2011. Caesarean section (CG132). [Online]. Available at: https://www.nice.org.uk/guidance/cg132

NHS Litigation Service, 2016. NHSLA Risk Management Standards 2013-14. [Online]. Available at: http://www.nhsla.com/Safety/Documents/NH'S%20LA%20Risk%20Management%20Standards%202013-14.pdf

Office of National Statistics, 2015. Birth characteristics in England and Wales: 2014. [Online]. Available at: http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/birthcharacteristicsinenglandandwales/2015-10-08

Royal College of Obstetricians & Gynaecologists, 2016. Guidelines. [Online]. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/

 

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