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KJSA logoPregnancy and maternal health

Pregnancy: Headlines

There are more than 5,000 live births every year in Kirklees; around half of these are to new mothers.

A healthy pregnancy is more likely to lead to a healthy birth weight and better health in later life.

The birth rate amongst south Asian women is much higher than non-south Asian women. Over half of live births in Dewsbury and Batley are to women of south Asian origin.

Women in more deprived areas are more likely to have a baby, and are more likely to have a low birth weight baby.

Women are encouraged to book an appointment with a midwife as soon as they know they are pregnant so they can have a full health and social needs assessment as early as possible and any additional support, advice and information needed can be given in plenty of time before their baby is born. 1 in 10 women do not book an appointment before 13 weeks of pregnancy.

Pregnancy: Why is this issue important?

The birth of a child is a major event for any family. Getting a good start in life is critical to lifelong development; the most serious damage can take place before birth and during the first 18 months of life when formation of the part of the brain governing emotional development is taking place. The antenatal period is as important as infancy to the outcome for a child, because maternal behaviour has such strong impacts on the developing foetus.

A healthy pregnancy – without smoking, with a healthy diet and with good mental health – is more likely to lead to a healthy birth weight, which in turn contributes to better health later in life.

Out of 6,120 pregnancies in 2010/11 there were 5,821 births to Kirklees women. The overall birth rate was 67 (per 1,000 women aged 15-44). The stillbirth rate was slightly higher than the national rate (5.1) at 5.3 per 1,000 births.

In August 2011 there were 55,180 families with dependent children (those claiming Child Benefit) . Of those nearly half (46%) had only one child, a third (37%) had two children and a fifth (18%) had three or more. This provides a proxy for the proportion of births to first time mothers.

Low birth weight (less than 2,500g) is a risk factor for infant deaths1. Locally more babies were born with a birth weight under 2,500g; than nationally (85 per 1,000 live births compared with 73 nationally).

Accessing antenatal care as early as possible can reduce the chance of having a low birth weight baby and factors such as diabetes and other diseases, smoking, drugs and alcohol use can be more effectively managed.

In 2011/12 there were 5,843 live births to Kirklees women. Out of the 6,120 pregnancies in Kirklees in 2010/11, 89% had their initial assessment before 13 weeks of gestation.

Pregnancy: What significant factors are affecting this issue?

In order to focus on women and families who are more vulnerable to poorer outcomes for themselves and their babies, pregnancy care needs to be delivered through more community-based maternity services, using community midwives and skill mixing with Maternity Support Workers and volunteer-based peer supporters.

Investment in staffing resource and changing ways of working is vital. Whilst over 88% of women are booking into maternity services before 13 weeks of pregnancy there are still around 10-12% of women who book later than this. Although insight shows that some women do not know they are pregnant until well after 12 weeks and many others prefer to “conceal” it, a better understanding is required about the needs of the women and families who do not book into maternity services within 13 weeks. Many of these families may be from communities who are particularly vulnerable to poorer outcomes for their babies and themselves.

Pregnancy: Which groups are most affected by this issue?

The number of live births and birth rates ranges from 1,028 births at a rate of 77 per 1,000 women aged 15-44 in Dewsbury and 629 births at a rate of 78 in Batley to 826 births at a rate of 50 in Holme Valley and 49 in Denby Dale & Kirkburton.

The low birth weight rate is highest in Batley (119 per 1,000 live births), Birstall & Birkenshaw (116) and Dewsbury (101). North Kirklees has a higher rate of low birth weight (95) than Greater Huddersfield (75) which is close to the national average. There is a higher rate of low birth weight amongst south Asians (120) than non-south Asians (85).

The live birth rate is closely linked to deprivation. The least deprived IMD quintile had a birth rate of 51 and this increases for each quintile with the most deprived quintile having a birth rate of 81. The pattern of low birth weight shows the opposite gradient with the least deprived quintile having a rate of 76 (per 1,000 live births) and the most deprived having a rate of 114.

There is a marked difference in birth rates between south Asian (100) and non-south Asian women (58). Within Batley and Dewsbury over half of live births (57% and 54%) were to women of south Asian origin, this is much lower in other areas.

Pregnancy: Views of local people

Recent insight gained from women and maternity services staff in North Kirklees illustrates some of the issues around workforce capacity and capability. In general terms women reported being satisfied with the antenatal care they received, with the relationship with their midwife being the most critical factor.

Levels of satisfaction were higher with antenatal services compared with satisfaction with delivery and postnatal services:

“The trainee midwives are better than proper midwives ’cos they have time for you and they don’t look down at you.” (White woman, aged 20 years, 1st baby)

“Auntie Pam’s was really good. I got all the information there as my midwife didn’t give me any.” (White woman, aged 20 years, 1st baby)

Asian women in particular reported high levels of satisfaction, though didn’t give much detail as to why or what made their care good. In some examples the care had clearly not been good. For example, an Asian woman with diabetes who was 28 weeks pregnant was seen in the delivery suite as she was having complications.

“I was in a wheelchair for 2 hours on corridor as they had no beds. I told them I had baby pain but they were very busy. Two hours later when they checked me I had lost the baby.”

Despite this, the woman was extremely positive about the care she received in her previous pregnancy when she miscarried:

“They are all very busy” (37-year old south Asian female, speaking limited English, 5th pregnancy)

During discussions with service users the terms “good midwife” and “bad midwife” were frequently used. A “good midwife”, described by women who were happy with their care, was one who was seen as available and contactable, has time for the woman and is interested in them, not just the baby (e.g. discusses domestic abuse), offers the right information when needed, doesn’t just bombard the woman with loads of leaflets at booking in. Women feel they have a good relationship with these midwives, as they are pleased to see them and are reassuring.

Despite this, there was an apparent lack of knowledge regarding the problem of infant mortality in Kirklees. The majority of staff were not aware that infant mortality was a specific issue for Kirklees.

Experience on the postnatal ward was generally positive. Women reported they wanted a midwife who had time to sit with them and help with practical things like feeding, bathing etc.

The overriding concern of most women following delivery was feeding. Those wanting to breastfeed (particularly first time mums) felt they needed a lot more support than they actually received:

“I was discharged pretty much straight away but I would have liked more support with feeding.”

(White woman, aged 39 years, 1st baby)

All women who were asked were positive about the initial postnatal support received from the community midwives and then subsequently health visitors, but these staff sometimes feel they are “starting from scratch”.

“Sometimes we see women in the community after they have been discharged from the (postnatal) ward and they still don’t know how to take basic care of a baby. We are starting from scratch. It’s because they don’t have time on (the postnatal ward) now.”

Pregnancy: What could commissioners and service planners consider?

  • The two strategic service transformation reviews need to prioritise healthy pregnancy as part of a shared vision to give every child the best possible start in life.
  • Service models need to be reviewed and agreed, putting service users and communities at the heart and engaging them in the process of transforming services.
  • The transformation of maternity services needs to prioritise the “normalisation” of pregnancy and birth, putting women in control of their pregnancy, so that every woman feels in control over her choices and the need for “medical” interventions is reduced.
  • Women need to be fully informed and involved in the decisions about their pregnancy and the birth of their child. Women and families need to have equitable access to high quality services centred around the woman, her baby and her family’s needs. This should enable her to have as normal a pregnancy and birth as possible and as appropriate, taking account of both her and her partner’s wishes.
  • From the insight described above, further work is needed to look more closely into whether Asian women are genuinely satisfied with their pregnancy care or whether there are cultural barriers and differences which inhibit their feedback. Ideally this would be done using peers from inside the community to enable open feedback.
  • The greater use of peers in the antenatal and postnatal process, including breastfeeding peer support, needs to be considered (e.g. service users supporting “parent craft” to talk about their experiences). This kind of peer support is offered through the volunteer led Auntie Pam’s and is working very well for the women who access that service.
  • A women-centred, midwife led, less medical service model is required that supports women to plan their pregnancy and birth. These birth plans should be seen as the “default” option, but should include further options to allow for changed circumstances.
  • Further work is needed to engage more Asian women in birth planning and preparation. Whilst considerable progress has been made over the last few years to improve the access of this group into maternity services (with huge success) it should be noted that they are not necessarily actively engaged with the birth preparation process. “Parent craft” classes in their current form are unlikely to engage many of these women, therefore specific alternatives should be considered.
  • In order to support the “normalisation” of pregnancy and birth, and reduce the over-reliance on medical (and higher risk) interventions, the model of services needs to ensure that women have increased access to home births, midwife led units, home-from-home facilities and options such as birthing pools. These options should be available as standard and obstetric/medical care only required as the exception rather than the norm.This requires redirection of resources towards community models of care, women-centred and midwife led, workforce redesign and development, culture change and a “mixed economy” of capability and capacity, such as greater peer support, skill mixed teams, integrated with others providing psychological, social and economic support.

Pregnancy: References

1. Child Benefit Statistics Geographical Analysis. HMRC; August 2011. Available from: http://www.hmrc.gov.uk/statistics/child-benefit.htm#2

Pregnancy: Date this section was last reviewed

09/07/2013 (PL)

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Maternal health: Headlines

Women play a central role in shaping the health of their children and families, both during pregnancy and through behaviours which continue into later life.

Maternal behaviours such as alcohol consumption, diet, physical activity, and particularly smoking during pregnancy, profoundly affect the health of the unborn child.

Amongst women of childbearing age 1 in 5 smoke, 1 in 6 smoked during pregnancy (excluding south Asian women), 1 in 4 regularly binge drink, but the overwhelming majority (87%) are not concerned about their drinking, only 1 in 3 are active enough to achieve health benefits and 1 in 6 are obese.

The highest rates of smoking (including during pregnancy), alcohol consumption and obesity are in areas of higher deprivation.

Maternal health: Why is this issue important?

There are over 80,000 women of childbearing age in Kirklees i.e. aged between 18 and 44. Of those more than 5,000 will have a child in any one year (see pregnancy and childbirth section). The 2011 Census showed that there are nearly 140,000 households with dependent children.

Stress, diet, drug, alcohol and tobbaco use during pregnancy impact on maternal health and have a significant influence on foetal and early brain development1. Women are usually the family shapers so their health and behaviour often has an impact on their families.

Maternal behaviours such as alcohol consumption, diet, physical activity, and particularly smoking during pregnancy, profoundly affect the health of the unborn child. The number of mothers with unhealthy behaviours varied across Kirklees but the highest rates of smoking were found in Dewsbury and Huddersfield South, alcohol consumption in Dewsbury and Birstall & Birkenshaw, and being overweight or obese in Birstall & Birkenshaw and Denby Dale and Kirkburton. As well as impacting upon infant deaths, maternal obesity has been found to be a major factor in more than 1 in 3 (35%) maternal deaths nationally3.

In Kirklees, 61% of the infant deaths between 2002 and 2008 were in North Kirklees and there is considerable variation across the localities, with particularly high rates in Batley and Dewsbury in 2011. Although numbers are small these areas show fluctuating rates whilst the general trend is reducing elsewhere. In Kirklees overall, more than half (55%) of the infant deaths were born prematurely, before 37 weeks gestation, especially white babies in north Kirklees (65%). Overall, nearly 6 in 10 (58%) were of low birth weight2 (see children dying before their first birthday section).

Women with complex needs

Services, and to some extent this JSNA, group people under only one aspect of their lives, such as those who are unemployed, smokers, victims of crime and those with long-term conditions. However what is not often captured is the holistic picture of all aspects of an individual’s life. People might be parents, grandparents, employed, in poverty, drinking excessive amounts of alcohol, carers, and eating a nutritionally poor diet all at the same time.

Maternal health fig 1

This chart aims to capture the range and complexity of needs that people have. These are people who have many aspects of their lives that are in turmoil and a crisis in one of these aspects can drastically affect every other.

If people have one simple problem or aspect of their life that they need support in, such as a housing problem that can be solved by one standard public service, then services can provide good solutions. But when people have many problems or problems that don’t match pre-existing services the welfare state can struggle to help them effectively.

There are a proportion of women who are experiencing domestic violence, using drugs or alcohol, in trouble with the police, and unemployed. Often one issue seems to create another problem or make related needs much worse. There are often not just the individual women who are experiencing problems; most are mothers and their children are often also suffering15.

These women are facing some unusually heavy burdens of fear, shame and misery. These burdens make solving day-to-day problems very hard and they make thinking positively about the future almost impossible. There is also a significant cost to society and public services because some fundamental issues are not deal with; rather presenting issues are addressed by each service or organisation in isolation.

Maternal health: What significant factors are affecting this issue?

Smoking in pregnancy

Smoking in pregnancy is a major cause and effect of avoidable differences in health between groups as it increases the risks of both prematurity, low birth weight and, thus, infant deaths. It contributes to other pregnancy complications such as placental insufficiency, high blood pressure, deep vein thrombosis and many others3.

While many women do stop smoking during pregnancy there is also a high relapse rate among them4. Nationally, 13% of women smoked at delivery during 2011/125. The promotion of a smoke free home can be a positive way in which the topic of smoking can be raised with a client. Research has shown that many families who make their homes smoke free later go on to stop smoking even where this was not their initial intention6,7.

Antenatal care (see pregnancy and childbirth section)

In 2011 90% of Kirklees mothers booked in for antenatal care before 13 weeks of pregnancy. Although this is an improvement on 2008, the remaining 10% are a concern. These women may not have had access to vitamins necessary to support foetal development and maternal wellbeing. Locally, Healthy Start vitamins (including vitamin D) are promoted and distributed through maternity services and more accessible venues such as Children’s Centres, and so is much wider than the national scheme.

Women planning a pregnancy are recommended to take folic acid supplements prior to conceiving and for the first 12 weeks of pregnancy8. This supplement can help to prevent neural tube defects in the foetus, protect against spina bifida and other malformations. For those women who do not book for maternity care, this simple but effective action can be missed. While there is no specific data on uptake of folic acid in pregnancy, a local study in 2008 suggested that less than 50% of pregnant women took this supplement12. Overall around 1 in 3 women of childbearing age in Kirklees have insufficient levels of vitamin D. In 2010, 16% of women aged 17-44 in north Kirklees who had lab tests, and 18% in south Kirklees were vitamin D deficient. And just under 16% in north and 12% in south had insufficient levels of vitamin D i.e. below the recommended level. Women who do not access antenatal care also miss out on opportunities to receive advice on health behaviours during pregnancy.

Maternal health: Where is this causing greatest concern?

Locally in 201213:

  • Just over 1 in 5 (21%) of women aged 18-44 smoked, a reduction of 2% since 2008. However, although there was a reduction in Huddersfield North, levels in Dewsbury, Spen and Huddersfield South were all above the Kirklees average. Dewsbury continues to have the highest rate at 27%.
  • Smoking rates were highest in women aged 18-44 in the most deprived IMD quintile (26%), compared with 16% in the least deprived quintile.
  • 1 in 6 (16%) women of childbearing age (excluding south Asian women) smoked during pregnancy. This varied from 1 in 3 (32%) in Dewsbury to just 1 in 50 (2%) in Denby Dale & Kirkburton.
  • 26% of women aged 18-44 reported they regularly binge drink, an increase since 2010 (11%). Dewsbury (34%) and Birstall & Birkenshaw (32%) had the highest levels of binge drinking.
  • 83% of women aged 18-44 were not concerned about their drinking.
  • Over 1 in 3 (34%) women aged 18-44 reported that they were active enough, i.e. did more than 30 minutes of physical activity five times per week, a slight increase since 2008. Denby Dale & Kirkburton had the lowest rate at 28%, followed by Birstall & Birkenshaw at 31% – both had reduced since 2008.
  • Levels of obesity amongst women of childbearing age for the whole of Kirklees remained the same since 2008 (17%); however, some localities had seen a rise – in Birstall & Birkenshaw from 13% to 20%, Dewsbury from 17% to 21%, and Huddersfield South from 16% to 20%. Levels of obesity were higher in BME women aged 18-44 – 20% compared to white women at 16%.
  • 2 in 5 (40%) women aged 18-44 were either obese or overweight, a slight reduction on 2008.
  • Levels of obesity and overweight were highest in women aged 18-44 in the most deprived IMD quintile.

Maternal health: Views of local people

Local insight revealed that societal norms, expectations and influences of family and significant others have a major impact upon maternal health behaviours14.

“If I tell him I have stopped and then he has bought some, I am back on the habit again. It’s sometimes the other way round – he tells me he has stopped. Why can’t we both go through phases where we will try and give up?”

(18-25 year old smoker)

Women also trusted the experiences of their friends and family rather than professional advice.

“With everything now, just in case anyone sneezes they would sue the Government so I think it’s just wrap everyone up in cotton wool and they’ll be all right. We were all right when we were growing up.”

(18-25 year old mother)

Some of the barriers to achieving a healthy diet were identified as cost.

“I got my little girl a bag of grapes and it is £2.50. Not being funny, but I could go and buy a pizza, chips and four tins of beans for that price.”

(18-25 year old mother)

And also time.

“You have to prepare it [fresh vegetables] and then it takes 20 minutes to boil and you have to mash them. Then there is all the washing up to do…”

(26-40 year old)

Local research6 has uncovered some of the complex factors involved in women’s motivation regarding smoking.

“Yeah, we do smoke and we do feel guilty for it, it’s not easy for everybody to stop smoking like that. But that is disgusting how you want to make us feel that bad that we’re gonna stop smoking.”

(26-40 year old smoker)

Maternal health: What could commissioners and service planners consider?

Continue to use research findings, along with the demographic data to inform the development of targeted action across the linked programmes of food, tobacco, alcohol and physical activity.

Focus on Dewsbury, Batley, Birstall & Birkenshaw, Spen, Huddersfield North and Huddersfield South given the levels of unhealthy behaviours of women of childbearing age (WOCBA) and infant deaths in those localities.

Key actions include:

  • Ensure all health professionals give consistent messages about food, physical activity, alcohol and tobacco, especially to women of childbearing age.
  • Ensure all services in contact with women of childbearing age undertake brief interventions training.
  • Support women to feedback to services to ensure that their needs are met.
  • Enable further development of peer support delivery based on current insight and understanding of lifestyles, circumstances and choices of women of childbearing age. This will support women seeking solutions to issues, and offer personal development to volunteer peer supporters as they aspire to achieve, contributing to the building of individual and community assets.
  • Target specific groups of women for specific activities according to identified needs:

o          Stop smoking groups in antenatal settings and fast track referral for all pregnant women and support for relapse prevention.

o          Place stop smoking advisers in Children’s Centres and other settings accessed by women.

o          Create a smoke free home for the developing child.

o          Implement current Department of Health (DH) guidance about alcohol in pregnancy and screening of hepatitis.

o          Provide a physical activity programme for pregnant women.

o          Provide a programme of dance for teenagers.

o          Implement Healthy Start scheme more widely.

o          Provide “cook and eat” schemes for women and their families.

  • Encourage professionals to act as advocates in relevant planning systems for the health behaviours of women of childbearing age. This should focus on preparing to be a parent, being pregnant and being a parent, and the effect of these behaviours. Professionals need to take a broad approach, targeting women of childbearing age before they become pregnant or even plan pregnancy as well as promoting healthy lifestyle choices for pregnant women and women who already have children10.
  • Develop confidence for self-management of issues amongst women with complex needs.
  • Encourage long-term support for change and self-improvement.
  • Take a holistic approach and increase sharing of information and resources.
  • Shift away from isolated and discrete project funding to a commission that would deliver an effective service across the target group, responding to multiple needs.

Maternal health: References

  1. Marmot M. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post 2010; 2010. Available from: http://www.marmot-review.org.uk/
  2. Vergis M. Infant Deaths in Kirklees 2002-2008. NHS Kirklees; 2010.
  3. Confidential Enquiries into Maternal and Child Health (CEMACH) Saving Mothers’ Lives. London: CEMACH 2007.
  4. Lumley J, Oliver SS, Chamberlain C, Oakley L. Interventions for Promoting Smoking Cessation During Pregnancy. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD001055. DOI: 0.1002/14651858.CD001055.pub2.
  5. NHS Information Centre. Smoking at Time of Delivery; 2012. Available from: http://www.ic.nhs.uk/
  6. Farkas A, Gilpin E, White M, Pierce J. Association Between Household and Smoking Restrictions and Adolescent Smoking. JAMA, 2000. 284: p. 717-722.
  7. Pizacani B, Martin D, Stark M, Koepsell T, et al. A Prospective Study of Household Smoking Bans and Subsequent Cessation Related Behaviour. Tobacco Control; 2004. 13(1): p.23-8.
  8. NICE. Antenatal Care: Routine Care for the Healthy Pregnant Woman. CG62 Guideline. 2008.
  9. Lavender T et al. Access to Antenatal Care: A Systematic Review; 2007.
  10. Department of Health. Maternity Standard, National Service Framework for Children, Young People and Maternity Services; 2004.
  11. Department of Health/Partnerships for Children, Families and Maternity. Maternity Matters: Choice, Access and Continuity of Care in a Safe Service; 2007.
  12. Smith H. Maternity Care Report: Final Draft Professional and Community Consultation; 2008.
  13. NHS Kirklees and Kirklees Council. Current Living in Kirklees (CLIK) Survey; 2012.
  14. Kirklees Partnership. Exploratory Research into Health of Women of Child Bearing Age. Prepared by 20/20 Research Limited, Sheffield; 2008.
  15. Duffy S, Hyde C. Women at the Centre – Innovation in Community. Centre for Welfare Reform & The Foundation for Families; 2011.

Maternal health: Date this section was last reviewed

09/07/2013 (PL)