Preconception, Pregnancy & Birth

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• A planned pregnancy is likely to be a healthier one, as unplanned pregnancies represent a missed opportunity to optimise pre-pregnancy health.
• Currently, 45% of pregnancies and one third of births in England are unplanned or associated with feelings of ambivalence
• One in seven couples find achieving pregnancy a challenge – Biologically, the optimum period for childbearing is between 20 to 35 years of age. Beyond the age of 35, it becomes increasingly difficult to fall pregnant, and the chance of miscarriage rises.
• 69.2% of pregnant people have their booking appointment with a midwife within 10 completed weeks of their pregnancy in SNEE LMS (2018-19)
• Maternal obesity can increase risk of: miscarriage, gestational diabetes, perinatal complications, stillbirth, metabolic abnormalities
• Smoking in Pregnancy can increase risk of: premature birth, miscarriage, perinatal death, low birthweight, ENT problems, respiratory conditions and diabetes
• 25.8% take folic acid supplements before pregnancy (2018-19)

• 12.7% in NEE smoke at time of delivery – higher than national average, although both East and West Suffolk rates are similar to national (9.3% & 8.8%) with Mid Suffolk and Ipswich both lower (5.5% & 4.9%)
• Smoking during pregnancy has been linked to health issues including premature birth, low birth weight, cot death, miscarriage and breathing and being overweight or obese also raises the risk of some pregnancy problems, such as high blood pressure, deep vein thrombosis, miscarriage and gestational diabetes.

More data:http://Child and Maternal Health – Data – OHID (phe.org.uk)

• The rates of multiple births are similar to the national average
• The proportion of low birth weight babies is lower than the national average in West Suffolk and similar to England average in the other areas of SNEE
• Breastfeeding initiation is lower than the national average in SNEE

More data: Here

• Inequalities are there but masked in our data
• Babies born in the most deprived areas are at an 80% higher risk of stillbirth and neonatal death compared to those living in the least deprived areas.
• Women living in these areas are almost three times more likely to die themselves. As the level of deprivation increases, the risk of dying in pregnancy, birth or the year after birth increases.
• Data shows there is an almost two-fold difference in mortality rates between women from Asian ethnic groups and white women, and they are also higher for black women. Black women are 40% more likely to experience a miscarriage than white women, and women living in deprived areas can have higher rates of stillbirths.

Having staff inform me of any issues, or even tell me when they need to leave the room during my time in hospital helps me not to feel abandoned or fearful. I understand staff are under strain, I want them to work alongside me.

Human Fertilisation and Embryology Authority (HFEA) 2021 survey of people using NHS and private services found:

• 7 in 10 patients were satisfied with their latest experience of fertility treatment, with almost 2 in 10 dissatisfied.
• Of those dissatisfied with treatment, issues included costs, not being treated as an individual, or being treated with a lack of compassion. Many same-sex couples were dissatisfied with how they were treated:

“The whole process as a gay couple has been demoralising and upsetting, from the cost of the treatment, to the disorganisation of the clinic and lack of clarity around a ‘shared motherhood’ cost package”

• 78% spoke to a GP prior to starting treatment. Less than half were satisfied with their experience, some feeling ignored or being treated with a lack of empathy, and waiting times for investigations or surgery.

“The GP kept forgetting to refer us…This happened a few times, costing me what I believed to valuable time for my fertility in my mid-thirties”

• Treatment generally started within 6-18 months of seeing a GP – a quarter waited over 18 months. Those waiting longest were primarily those using only NHS services and ethnic minority patients.

An HFEA survey explored the impact of COVID-19 on access to, and experience of fertility treatment:

• Respondents were twice as likely to report a delay to starting treatment if they were NHS-funded (41%) compared to privately funded (21%).
• Respondents mentioned concerns over restrictions in partner attendance to clinic appointments, NHS waiting lists and the use of online/phone appointments.

Preconception can be defined from a range of perspectives:

• biological – the days and weeks before embryo development
• individual – the time of wanting to conceive
• population – any time a woman is of childbearing age

The government’s Women’s Health Strategy published August 2022 has a number of ambitions focused on improving pregnancy outcomes and giving children the best start in life including:

• high-quality, evidence-based education to children on fertility, contraception and pregnancy
• high-quality information, education and to support people to make informed decisions about their reproductive health, to access to their preferred type of contraception and to help optimise their health and wellbeing prior to conception
• tackling the current geographical variation in access to NHS-funded fertility services across England, in particular for same-sex couples and providing evidence-based information about privately funded fertility treatment ‘add-ons’ so patients are better able to make informed choices.

The strategy highlights measures to optimise health in preparation for pregnancy including:

• having vaccinations, sexual health checks and screening
• a healthy diet, taking Vitamin D and folic acid supplements, reducing alcohol and giving up smoking
• targeted approaches for the most vulnerable and higher risk people and families

The LGBT Foundation’s recent report on Improving Trans and Non-binary Experiences of Maternity Services (ITEMS) found:

• Trans and non-binary people’s experiences of perinatal care are consistently worse across the board compared with cis women. This is also reflected in the proportion of trans and non-binary birthing parents who didn’t access any perinatal care during pregnancy – 30%, compared with up to 2.1% of the general population.
• Transphobia and racism in perinatal care intersect to produce particularly poor outcomes for trans and non-binary birthing parents of colour.
• There are examples of good practice, where midwives and services as a whole take a proactive approach to gender inclusion, from language used to provide care options that clearly centred the needs of the individual patients. However, these were generally localised and not supported at a wider scale by the necessary resources for training/development and national-level guidance.

The report recommended:

• Supporting the delivery of personalised and trauma-informed perinatal care
• Proactively adopting inclusive language and targeting outreach to trans and non-binary birthing parents
• Implementing IT and demographic monitoring systems to enable the sensitive collection of data about gender identity and trans status in perinatal services.

The Royal College of Obstetricians and Gynaecologists highlights:

• Black, Asian, and minority ethnic women can receive a lower quality of care and experience poorer health outcomes, including higher rates of morbidity and mortality, than other women.
• Implicit racial bias from medical staff can hinder consultations, negatively influence treatment options and can ultimately result in Black, Asian and minority ethnic women avoiding interactions with health services
• Medical research must become more inclusive to ensure that all girls and women get the right advice and treatment.

NHS Race and Health Observatory review of evidence of ethnic inequalities in healthcare highlighted:

• Communication: A lack of trust, insensitive behaviour, lack of active listening by providers, and failure to bridge cultural differences. For those without English skills, a lack of accessible and high quality interpreting services.
• Experiences: Negative interactions, stereotyping, disrespect, discrimination and cultural insensitivity. System-level factors, and the attitudes, knowledge and behaviours of healthcare staff, make some feel ‘othered’, unwelcome, and poorly cared-for. These factors undermine trust and feed fear, leading to poorer access to, and engagement with services.
• Access to community services: Ethnic minority women feel underserved by community-based services.
• Deprivation/disadvantage: The intersection of additional aspects of social disadvantage can further compromise access to, and experiences of, maternity care. Groups of particular concern include Roma, Gypsy and Traveller women, asylum seekers or recent refugees, those with mental health conditions, teenage and young parents.

During pregnancy, people with health conditions may be taking medication which gives rise to concerns about the impact on the unborn. Women taking medication for their mental health face dilemmas in whether to discontinue their treatment during pregnancy.

• Some medications can impact the unborn child, though there is a lack of robust evidence.
• Stopping medication could lead to relapse.

Research into discontinuation of antipsychotic medications shows those who are younger (under 35) and those who have been taking their medications for less than a year are more likely to cease their medications in pregnancy.

Research into depression during pregnancy found that women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication.

New parents can experience a range of emotional and mental health issues:

• Difficulty concentrating, poor memory, difficulties sleeping
• Practical and financial worries about coping with a new baby
• Unwanted and upsetting thoughts, heightened emotions
• Depression, anxiety and panic attacks, Perinatal Obsessive Compulsive Disorder
• Post partum psychosis
• Impacts of birth trauma

In ‘Why we need to talk about losing a baby’ the World Health Organisation lists 5 key messages around support in maternity care internationally:

1.It can be difficult to know what to say when someone you know loses a baby in pregnancy, but sensitivity and empathy can provide support and allow space for people to talk about how they feel

2.The experience of losing a baby may differ around the world, yet stigma, shame and guilt emerge as common themes.

3.Many women who lose a baby in pregnancy can go on to develop mental health issues that last for months or years– even when they have gone on to have healthy babies.

4.We know how to save more babies dying in pregnancy – improving access to antenatal care (in some areas in the world, women do not see a health care worker until they are several months pregnant), introducing continuity of care through midwife-led care, and introducing community care where possible.

5.Every year, nearly 2 million babies are stillborn, and many of these deaths are preventable. Integrating the treatment of infections in pregnancy, fetal heart rate monitoring and labour surveillance, as part of an integrated care package could save 832 000 babies who would otherwise have been stillborn.

In recent years, nationally, there has been a series of investigations and inquiries into poor quality care delivered in NHS maternity services.

The recent Ockendon report into Maternity Services at the Shrewsbury and Telford Hospital NHS Trust stated:

‘Repeatedly, families have told us of two key wishes. Firstly, they want questions answered in order that they understand what happened during their maternity care. Secondly, they want the system to learn, so as to ensure that any identified failings from their care are not repeated at the Trust or occur at any other maternity service in England.’

‘there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change.’

 

One of the key recommendations from the Kirkup report in October 2022 Reading the signals: Maternity and neonatal services in East Kent concerns recognising harm and tackling problems in partnership with families:

Recommendation 5: The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input.

Child and Maternal Health – Data – OHID (phe.org.uk)
Health matters: reproductive health and pregnancy planning – GOV.UK (www.gov.uk)
Physical Health State of Children in Suffolk 2022 (healthysuffolk.org.uk)
SACN_report_on_Feeding_in_the_First_Year_of_Life.pdf (publishing.service.gov.uk)
Breastfeeding (who.int)
Health matters: reproductive health and pregnancy planning – GOV.UK (www.gov.uk)
Impact of COVID-19 on fertility treatment 2020 | HFEA
Women’s Health Strategy for England – GOV.UK (www.gov.uk)
RHO-Rapid-Review-Final-Report_v.7.pdf (nhsrho.org)
Discontinuation of antipsychotic medication in pregnancy: A cohort study – ScienceDirect
Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment – PubMed (nih.gov)
LGBT Foundation – Revealed: Improving Trans and Non-binary Experiences of Maternity Services (ITEMS) report
OCKENDEN REPORT – MATERNITY SERVICES AT THE SHREWSBURY AND TELFORD HOSPITAL NHS TRUST (publishing.service.gov.uk)
Why we need to talk about losing a baby (who.int)
Reading the signals: maternity and neonatal services in East Kent, the report of the independent investigation (print ready) (publishing.service.gov.uk)

 

 

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