Healthy Pregnancy

Why a Healthy Pregnancy is important

The first 1001 days of a child’s life represent a critical phase of heightened vulnerability, but also a window of enormous opportunity. Offering advice and support to parents provides an opportunity to help parents set the patterns for effective parenting and a nurturing environment during the early years of a child’s development and future life chances.^[1]

The circumstances and behaviours of parents 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. 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.

Core20PLUS5 is a national NHS approach to support the reduction of health inequalities at both national and system levels. The approach is targeted at supporting the most deprived 20% of the national population (IMD) ‘PLUS’ identified populations or communities that are not thriving. Maternity care is included in the adult Core20PLUS5 (there is a separate Core20PLUS5 for children and young people)[2].

The local picture

The most recently published data, with comparison to other local authorities of similar deprivation unless stated otherwise, as of June 2023.^[3]

Table 1: Healthy pregnancy in Bedford Borough

Healthy Pregnancy Indicator	Previous period  [Comparator IMD 2019] (Date)	Most recent available period [Comparator IMD 2019] (Date)
Smoking at time of delivery (%)
	7.0% [9.1%, England] [8.5%, Region] (2019/20)	7.3% [8.8%, England] [8.7%, Region] (2022/3)
Under 18s conception (Rate per 1,000)
	14.6 [N/A] (2019)	11.1 [12.7*] (2021
Under 16s conception (Rate per 1,000)
	2.0 [2.5] (2019)	2.4 [1.9*] (2021)
Infant mortality rate up to 1 year (Rate per 1,000)
	4.9 [3.8] (2019-21)	5.1 [3.7] (2020-22)
Early access to maternity care** (%)
	NA [NA] (2017/18)	77.6 [59.2%*] (2018/19

Bedford is statistically performing better than other local authorities of similar deprivation in relation to early access to maternity care, rates of smoking in pregnancy and the Under 18’s conception rate.

Over the last 18 years, there has been significant progress in addressing teenage pregnancy with the under-18 and under-16 conception rates falling by about 60%[5].

Infant mortality

There are around 2,223[6]  live births in Bedford Borough each year, and about ten babies die each
year before their first birthday. The infant mortality rate has been stable over the five years
2017-22 (4.8-5.1%).

Between April 2021 and end of March 2022, there were 43 infant deaths in Bedfordshire and Luton with 32 infants dying before 28 days. 26 of these infants were born prematurely[7].

Source: Korkodilos M (2023) Core20PLUS5: Maternity Reducing inequalities in outcomes for mothers and babies, OHID

Between April 2021- March 2022 the Bedfordshire and Luton CDOP (Child Death Oversight Panel) reviewed 39 child deaths that occurred 2019-2020 in Bedfordshire and Luton. Six of the reviewed child deaths had modifiable factors (defined as factors which, by means of nationally or locally achievable interventions, could be modified to reduce the risk of future child deaths), which is lower than the previous year and lower than the national figure of 31% (but figures vary considerably from year to year and fewer cases were reviewed in 2021-22 than in previous years). The category of death for children where a modifiable factor was found was Chromosomal; Genetic; Congenital (2), Perinatal/Neonatal (2) and SUDI/Unexplained Death (2). Modifiable factors were identified locally and are listed in order
1. Maternal High BMI 2. Consanguinity 3. Smoking In Pregnancy 4. Co-sleeping 5. Alcohol 6. Home Safety.

Local maternity services are in the process of implementing the ‘Saving Babies’ Lives Care Bundle’^[8] – a set of guidelines for reducing stillbirth. Risk assessments need to be undertaken throughout pregnancy and improvements made to monitoring foetal wellbeing. Women with complex pregnancies need to have a named obstetrician who has early involvement and input into management plans.

It remains important to continue to promote public health strategies to reduce risks of premature birth and low birthweight babies and to prevent babies dying in infancy or the neonatal period – including smoking cessation, healthy lifestyles, healthy weight, safe sleeping and access to related services. The data analysed in the 2021-2022 CDOP report suggests these messages and improving access to services are particularly important in areas of deprivation and with minoritized and mixed ethnic families who are disproportionately impacted. 

CDR partners need to continue to assure themselves that the findings from previous child death reviews where there were service modifiable factors have been addressed and used to reduce risk of future death and work to action other recommendations from the latest CDOP annual report.

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. Black, Asian and minority ethnic women are at a higher risk of dying during pregnancy, childbirth and postnatally and of experiencing premature death, stillbirth or neonatal death compared with their white counterparts[9].

Ensuring early access to a midwife, preferably by week 10 of pregnancy, will equip women with the knowledge and skills they need to address many preventable risks to their pregnancy. Currently almost 8 out of 10 women access a midwife before 10 weeks in Bedford Borough which compares positively with statistical neighbours and nationally.

A Cochrane review^[10] found that women who received midwife-led continuity of care were less likely to experience preterm births or lose their baby in pregnancy or in the first month following birth. They were:

• 16% less likely to lose their baby
• 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 and 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.

The ambition for the NHS in England is for Maternity Continuity of Carer (MCoC)[11] to be the default model of care for maternity services, and available to all pregnant women in England, with rollout prioritised to those most likely to experience poorer outcomes. However, whilst MCoC remains a national priority, due to the shortage of staffing the rollout of MCoC is on hold in many hospital Trusts until safer staffing permits. This remains challenging in most areas of England including Bedford.

In Bedford, 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. Co-produced tailored communication has been developed to reassure and encourage women from ethnic minorities to seek help if they have concerns.

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 families and to 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 facilitate this.

Following Covid, consultations are now completed face to face, either at a GP location or a Children’s Centre/Maternity Hub. A few women still have their booking completed via phone, but all antenatal appointments are face to face.

Smoking in pregnancy

Smoking during pregnancy causes up to 2,200 premature births, 5,000 miscarriages and 300 perinatal deaths every year in the UK.^[12] It also increases the risk of complications in pregnancy and the child developing a number of conditions later in life, including asthma[13]. Children born to parents who smoke are also more likely to become smokers themselves, which further perpetuates this inequality.^[14]

In 2022-23, 7.3% of women in Bedford were still smoking at time of delivery^[15]and it is estimated that around one in 9 babies live in a household with a smoker^[16]. Younger mothers (<25), those from White backgrounds and those in deprived areas are much more likely to smoke.^[17]

In 2020-21 Bedford 28 women set a quit date through the Stop Smoking Service, with 50% going on to quit successfully. In 2021-22, the stop smoking service received 73 referrals over a 10 month period for pregnant women living in Bedford Borough. This data suggests that not all women smoking at the time of delivery are referred to the service. From March 2023, the pathway has changed and pregnant women who smoke are supported in line with the NHS Long Term Plan Tobacco Dependence Treatment Programme. As a result, pregnant smokers are offered support by a Stop Smoking Adviser who is employed within Bedfordshire Hospitals Trust Maternity service. The intention is that all pregnant women who are smoking are referred.

The advisor will run through the harms of smoking to parent and baby and offer support to make behavioural and habitual changes, including provision of Nicotine Replacement Therapy (NRT) products to aid stopping.

All women now have carbon monoxide (CO) monitoring at every single antenatal appointment. Smokers and those with low CO levels are referred to the in-house maternity Stop Smoking Adviser. Smokers are referred for consultant led care and serial growth scans from 26 weeks until delivery.

The in-house Stop Smoking service continues to offer a rolling training programme to improve skills of service providers working with pregnant women. This supports a consistent and tailored approach to identifying pregnant women with tobacco dependence and ensuring that they access timely and effective 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.

Maternal obesity

Maternal obesity is defined as having a BMI of 30 kg/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.^[18] In 2018-19, 22.1% of women in Bedford were obese in early pregnancy, which was the same as the national average[19].

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.^[20] Maternal obesity varies significantly across communities and social groups, particularly across age, deprivation and ethnicity. The proportion of women (2017) nationally who were obese in pregnancy[21]:

• increased with age, with the highest proportion (21.5%) in women aged > 40 years, which was which was 2.2x higher than women <18 and 1.3x higher than women >30-34
• was about 2x higher for women living in the most deprived areas (23.3%) compared to women living in the least deprived areas (12.6%)
• was 6.6x higher in Black women (28.7%) and 4.3x higher in White women (18.5%) compared to Chinese women (4.3%).

Diet and exercise interventions during pregnancy 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. In Bedford, women with a booking BMI greater than 27.5 can be referred to:

• MoreLife MUMS2B which is focused on balanced health behaviours and the prevention of Gestational Diabetes. Women are able to choose what topics they want to know more about with a minimum of 4 x 20mins 1-2- 1 phone consultations with a choice of timings across the week. MUMS2B is for women who are pregnant and up to four months post birth.

• Morelife 4MUMS focuses on postnatal weight loss and prevention of Type 2 Diabetes, particularly for those who have had Gestational Diabetes. It runs alongside existing Tier 2 group programmes held at a variety of community venues or digitally on Zoom, including four 1-2-1 sessions. Women can choose to attend either 10-week Family Programmes (with children) or 12-week Adult Programme (without children). Women with a booking BMI greater than 30 are referred on an ‘opt-out basis’.

Support is delivered as a whole family approach to change and embed healthy behaviours and is linked with other public health messages in pregnancy such as smoking cessation. Work has started across BLMK around preconception advice and care.

Teenage parents

In 2021, there were 35 under-18 conceptions[22]. 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 that is trusted by young parents and focused on building their skills, confidence and aspirations.

Mothers under 20 years of age are historically:^[23]

• three 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.

Individual level risk factors for teenage pregnancy include[24]:

• Drug and alcohol use
• Experience of a previous pregnancy
• Experience of sexual abuse
• First sex before 16
• Lack of knowledge about sex or contraception
• Low self esteem
• Poor school performance

Family risk factors include ethnicity; family history of teenage pregnancy; frequent family conflict; living in care and being from a lower social class. Social risk factors include dating someone who is older and pressure from peers to have sex. 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 Bedford, 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.

All young parents are contacted at point of referral into the children’s centre, whether it be antenatal or postnatal to offer universal or targeted support for example parenting. They are then invited to the weekly young parents group which is well attended. The team have gathered parent feedback, regarding what young parents would like to see. A plan has been created, to incorporate support around introducing solid food, sensory, messy and soft play and picnics in the park. Service users have stated the importance of the non-judgemental and relaxed environment which has supported peer engagement into the group.

Maternal and paternal mental health

During the perinatal period (pregnancy and the first year following birth), poor maternal mental health has important consequences which can impact the mother, infant, family and wider society[25].

Impact on the mother:

• Without treatment, perinatal mental health problems can lead to a range of adverse psychological, social, parenting and employment outcomes
• Maternal death by suicide in the UK is the leading cause of direct deaths for women during the perinatal period

Impact on the child and family:

• Increased risk of premature births and stillbirths, obstetric complications, congenital malformations and delayed physical growth
• Increased risk of behavioural and emotional problems for the baby later in life
•  Increased risk of impaired mother-baby interactions and parenting difficulties

Impact on wider society:

• Perinatal mental health problems are extremely costly to society
• Of the societal cost, 72% relates to lost productivity resulting from the adverse impact on the child over their lifetime.

About 1 in 5 women will experience a perinatal mental health problem which can range from mild to severe. Depression and anxiety disorders (such as generalised anxiety, social anxiety, obsessive-compulsive and post-traumatic stress disorders) are the most frequent, occurring in about 1 in 7 women in the perinatal period. Serious mental illness requiring admission is much less common, with around 2 to 3 women per 1,000 deliveries being admitted to a mother and baby unit. Postpartum psychosis is even less common, affecting one to two out of every 1,000 women who give birth[26].

Partners also experience paternal depression and national prevalence is estimated around 10%[27].

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, other parent/carers, the child and family. Risk factors include^[28]:

• a history of mental health problems, particularly depression, earlier in life
• a history of mental health problems during pregnancy
• having no close family or friends to support you
• a difficult relationship with your partner
• recent stressful life events, such as a bereavement
• physical or psychological trauma, such as domestic violence

In general, the UK BAME population is more likely to have poor mental health and this may be true in the perinatal period. During their perinatal period, women from different ethnic groups vary significantly in access to mental health services[29]. Young mothers up to the age of 25 years are also at particular risk of poor mental health, up to three years after birth[30] and higher levels of deprivation are associated with a higher prevalence of poor perinatal mental health[31].

A challenging consequence of the move to online antenatal services during the COVID-19 pandemic has been the increase in loneliness and isolation, with vulnerable mothers being able to more easily mask their mental health problems. Maternity services and staff have also highlighted increased maternal anxiety as a result of the pandemic and changes in service delivery. A return to face-to-face support will help the earlier identification of emerging mental health needs. There are numerous contact points where routine appointments are used to assess maternal (and to some extent paternal) health during pregnancy and the first 2 years, including antenatal classes, routine antenatal appointments, Health Visitor and 0-19 Team, GP and Children’s Centres.

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 that include a specialist perinatal mental health service in Bedfordshire. Perinatal mental health is a key focus within Bedford’s Start for Life and Family Hubs offer. 

A range of advice, assessment and treatment is available at different levels of need to meet maternal mental health needs:

• Self-help and community resources include online resources (MIND/NHS), family support groups (FACES) and Mind the bump/Mind the baby classes at Children’s Centres
• For mild to moderate mental health issues, midwifery and health visiting services offer specialist support and parents with moderate needs can access Bedfordshire Talking Therapies provided by the East London Foundation Trust (ELFT)
• For moderate and severe mental health conditions, parents have access to Bedfordshire Talking therapies and the Specialist Perinatal Mental Health service (ELFT). Specialist outpatient and community care is available to people who are pregnant or in their first year after having a baby. If needed, mothers can be referred to a specialist inpatient mother and baby unit.
• One off pre-conception counselling is available to people who have a history of severe mental illness and who are considering having a baby.
• CAMHS offer a specialist service to support where there are worries about the parent-infant relationship.
• OCEAN (Offering Compassionate Emotional Support for those Living Through Birth Trauma & Birth Loss) is an integrated maternity and mental health service providing support for those affected by birth loss or birth trauma.  This service has been co-produced by service users, voluntary sector organisations, maternity voices partnership and other NHS partners. This specialist service is provided by East London NHS Foundation Trust (ELFT) in partnership with Bedford Hospitals NHS Foundation Trust.

Work is ongoing to ensure that the perinatal mental health care pathways are clear and that professionals and parents are aware of the available options and choices.

Historically, community midwifery care has been delivered within GP practices. The experience of taking services into the community during Covid helped drive attendance, and aid relationships. For the first time many maternity services or family services were being offered in the same places. This has since led to development of Community Maternity Hubs where services for maternity care are being explored further as to what can be taken to the community to ensure that services meet the needs of our community. Bedford Hospital Community midwifery teams have identified premises and implementation will commence April 2023.  Maternity Hubs enable women and families to be seen at one central location for their antenatal and postnatal care and to receive continuity of care which is provided by a small team of midwives.  Maternity services are working closely with the local authority to align the development of maternity hubs with the family hubs agenda.

The National Better Births Maternity Review highlighted the importance of ‘continuity of care’ with a hub-based model of working.  The recent government publication ‘Best Start for Life’ report (2023) has reiterated this vision and the importance of early identification of need.

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 ‘Whole 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 Births^[32] 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 when safer staffing permits, 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 the referral pathways between perinatal mental health services to ensure they work seamlessly together to support the mother/parent and can step up/step down to the most appropriate service depending on need.
5. Develop and monitor effectiveness of reducing smoking in pregnancy through the Keeping Well in Pregnancy team.
6. Review Maternal Obesity Pathway against national guidance.

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References

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