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Maternity

Introduction

The Marmot Review into Health Inequalities (external link) highlighted the importance of giving every child the best start in life. The foundations for every aspect of human development are laid in early childhood. What happens during these very early years, starting in pregnancy, has lifelong effects on many aspects of health and well-being – from obesity, heart disease and mental health, to educational achievement and economic status. Development begins before birth, when the health of the baby is affected by the health and well-being of the mother. Inequalities are present prenatally and increase through early childhood. Maternal health, including stress, diet, drug, alcohol and tobacco use during pregnancy has significant influence on foetal and early brain development.

Disadvantaged mothers are more likely to have babies of low birth weight. In particular low birthweight is associated with poorer long term health and educational outcomes.

Infant mortality is linked to deprivation. See Infant mortality section for more details.

There is a wealth of evidence about the importance of breastfeeding in preventing infant infection, Sudden Unexpected Death in Infancy (SUDI) and child obesity (see footnote 1). Although rates of breastfeeding at initiation and at 6-8 weeks are high in Haringey compared to England, there remains inequality across the borough with fewer women breastfeeding in the east of the borough (see breastfeeding section below).

Immunisations, teenage pregnancy, smoking and childhood obesity are considered elsewhere.

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Key Issues and gaps

  • There are inequalities in access to maternity services before the recommended 12 weeks 6 days of pregnancy – those aged under 20 and Black African women living in the east of the borough are most likely to book for antenatal care after this time.
  • The social and demographic characteristics of the population in Haringey is reflected in high maternal health need.
  • There is a national shortage of midwives which will have an impact in Haringey particularly considering the increasing birth rate.
  • There are inequalities in breastfeeding rates. Women living in the east of the borough are least likely to be breastfeeding at 6-8 weeks.
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Who is at risk and why

  • Pregnant women with complex social factors are known to book later, on average, than other women and late booking is known to be associated with poor obstetric and neonatal outcomes. The following groups were chosen from groups highlighted in Saving Mothers’ Lives (external link) as having poorer pregnancy outcomes than the general population:
    • Women who are substance misusers (including drugs and/or alcohol)
    • Recent migrants, refugees, asylum seekers, and women with little or no English
    • Young women aged under 20
    • Women experiencing domestic abuse.
  • Black African women in Haringey are more likely to book late for antenatal care than White British women (see footnote 2).
  • Obese pregnant women – obesity in pregnancy is a risk factor for maternal deaths and infant mortality.
  • Women who smoke in pregnancy – smoking during pregnancy can cause serious pregnancy-related health problems. These include: complications during labour and an increased risk of miscarriage, premature birth, still birth, low birth weight and sudden unexpected death in infancy. Smoking during pregnancy also increases the risk of infant mortality by an estimated 40% (see footnote 3).
  • Age of mother – younger and older mothers are at higher risk of complications compared to women aged 20-39.
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The level of need in the population

Maternal death:

  • Maternal death is extremely rare. The latest data available 2006–2008, reveals that 261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003–2005 to 4.67 per 100,000 maternities in 2006–2008. More information can be found in Saving Mothers Lives 2011 - Saving Mothers’ Lives (external link).
  • In Saving Mothers Lives in general, the women who died appeared to be in poorer general health and smoked more, and over half were overweight or obese. Many also had chaotic lifestyles and found it hard to engage with maternity services. Bearing in mind the levels of deprivation in Haringey, it is likely that maternity services are dealing with women with potentially complex pregnancies.

Fertility rate:

  • The general fertility rate is the number of live births in a year per 1,000 women of child- bearing age (aged between 15-44 years).
  • In 2010, the general fertility rate for Haringey Primary Care Trust was 83.5 compared to 70.6 in 2006.
  • The fertility rate in England in 2010 was 65.4 and 72.1 in London for the same period.

This increasing fertility rate will impact on service provision in Haringey. See population chapter for more information.

Live births:

  • The number of live births in Haringey increased by 19.5% between 2002 and 2010 when there were 4,456 live births.
  • The highest number of births is in wards in the east of the borough.

Low birth weight:

  • The proportion of babies with a low birth weight (under 2500g) in Haringey has decreased considerably since a peak in 2003 of 9.3%.
  • In 2010, the proportion of births classified as a low birth weight birth was 7.1% in Haringey compared to 7.0% in England and 7.4% in London as a whole.
  • Wards in the east of Haringey tend to have higher proportion of low birth weight babies.

Figure 1: Low birth weight trend in Haringey, London and England.

Source: ONS VS2 files 2002 to 2010

Figure 2: Low birth weight by Haringey wards 2009 and 2010

Source: ONS Public Health birth files 2009 and 2010

Early access to maternity services:

  • The NICE guideline for antenatal care (external link)  recommends that pregnant women should receive a complete assessment (booking) by 12 weeks gestation (12 weeks and 6 days), but ideally by the 10th week.
  • Nationally, in 2010, 20% of women booked for antenatal care after 12 weeks 6 days gestation.
  • In Haringey, 40% of women booked after 12 weeks 6 days. Booking late for antenatal care is a significant public health issue as maternal and perinatal deaths are higher in women who book late.

The chart below describes antenatal bookings (the first appointment with the midwife) under 13 weeks gestation by age of mother in 2010 in Haringey.

  • Overall, nearly 60% of women are booking within the recommended timeframe; however there are differences between age groups.
  • Women aged under 20 are the least likely to book under 13 weeks (39% n=51) and most likely to book over 22 weeks (23% n=31).
  • The highest proportion of women booking under 13 weeks are those aged between 35-39 (64% n=426).

Figure 3: Antenatal bookings by gestation and age of mother 2010

Source: Whittington Hospital and North Middlesex Hospital Maternity Information Systems

There are also variations in terms of ethnicity.

  • Whilst the proportion of White British women who book after 22 weeks is as low as 4.5%, the proportion among BME groups is considerably higher; Black African 12.2%, Any Other Ethnic Group 12.2%, Black African 10.8% and Any Other White 8.6%.
  • When looking at all bookings after 13 weeks, the variation is even wider such that only 30% of White British women book late compared to 51% of Black African women.

Figure 4: Access by ethnicity

Source: North Middlesex Hospital and Whittington Hospital Maternity Information Systems

Figure 5: Trend in early access to maternity services for Haringey compared to London and England (quarter 3 2009/10 to quarter 2 2011/12)

Source: Department of Health

Recently Haringey’s performance is on a downward trend which is a cause for concern, particularly when compared to London and England. There are plans in place to improve performance

Infant Health – see infant mortality section of JSNA

Breastfeeding

There is a large body of published research which shows that breastfeeding has clear health benefits for both mothers and infants (see footnote 4). The data is collected at two stages. Firstly, initiation data is collected by the hospitals at time of delivery and secondly during the GP contact, 6-8 weeks after birth.

The chart below describes breastfeeding initiation comparing Haringey with London and England, and with the other boroughs in North Central London cluster.

Figure 6: Breastfeeding initiation comparing Haringey with London, England and boroughs in North Central London Cluster 2010-2012

Source: Department of Health Integrated Performance Measure Return, 2011

In London, the uptake of breastfeeding is considerably higher in each of the London boroughs in the North Central London cluster compared to rates in England as a whole. Haringey’s initiation rate is higher than London and also higher than each of the boroughs in North Central London.

Data collected at 6-8 weeks after birth includes babies that are receiving any breast milk and not necessarily those that are exclusively breastfed. Ward data in Haringey reveals that there are inequalities across the borough with wards in the east of the borough having lower breastfeeding rates than the west.

Figure 7: Breastfeeding at 6-8 weeks by ward 2010/11

Source: GP surgeries in Haringey

Smoking in pregnancy:

Smoking in pregnancy is a cause of ill health for the mother and baby. Babies of mothers who smoked during pregnancy:

  • are more likely to be born prematurely;
  • twice as likely to have a low birth weight;
  • up to three time as likely to die from sudden unexpected death in infancy (SUDI).

Smoking in pregnancy increases infant mortality by about 40%. See review of the health inequalities infant mortality PSA target (external link).

Smoking status at time of birth is recorded by the maternity teams at the hospitals. This is collected by the hospitals as part of the data set that they submit on a quarterly basis and therefore the data is only available at borough level. However, it is known that smoking during pregnancy is more likely amongst women in lower socioeconomic groups and as a result these women are likely to be living in the east of the borough where there are higher levels of deprivation.

Figure 8: Smoking during pregnancy in NCL, London and England.

Source: ONS VS2 files 2009 and 2010

Maternal Obesity - see Adult Obesity section for further information

BMI (body mass index) is a measure of weight in relation to height. A healthy BMI is above 18.5 and less than 25. A person is considered to be overweight if their BMI is between 25 and 29.9 or obese if they have a BMI of 30 or above. Almost one in five (20%) pregnant women have a BMI of 30 or above at the beginning of their pregnancy - management of women with obesity in pregnancy (external link).

  • Being overweight (with a BMI above 25) increases the risk of complications for pregnant women and their babies. With increasing BMI, the additional risks become gradually more likely, the risks being much higher for women with a BMI of 40 or above.

Risks for women associated with a raised BMI include:

  • Thrombosis
  • Gestational diabetes
  • High blood pressure and pre-eclampsia

Risks for babies associated with a raised BMI include:

  • Neural tube defects (although problems with the development of the baby’s brain and spine are uncommon - overall around 1 in 1000 babies are born with neural tube defects in the UK) – pregnant women with a BMI over 40, have three times the risk of a woman with a BMI below 30.
  • Miscarriage - the overall risk of a miscarriage under 12 weeks is 1 in 5 (20%), but the risk increases to 1 in 4 (25%) for women with a BMI over 30.
  • Stillbirth - the overall risk of stillbirth in the UK is 1 in 200 (0.5%), but the risk is doubled to 1 in 100 (1%) for women with a BMI over 30.
  • If the mother is overweight, the baby will have an increased risk of obesity and diabetes in later life.

There are also risks of a raised BMI during labour and birth:

Increased risk of complications during labour and birth, particularly for women with a BMI of more than 40. These include:

  • an emergency caesarean birth
  • a more difficult operation if you a caesarean section is needed and a higher risk of complications afterward
  • anaesthetic complications, especially with general anaesthesia
  • heavy bleeding after birth (postpartum haemorrhage) or at the time of caesarean section
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Current services in relation to need

  • The majority of women in Haringey access maternity services from either the North Middlesex Hospital or the Whittington Hospital.
  • Maternity services are commissioned at NCL sector level on behalf of the 5 boroughs.
  • Safer Childbirth - Minimum Standards for the Organisation and Delivery of Care in Labour (PDF, 544KB - external link) recommends a ratio of 1 midwife to 28 births. Latest figures for the North Middlesex Hospital (December 2011) has a ratio of 1:34 but there are plans in place to improve this figure. The ratio for the Whittington Hospital (December 2011) is 1:27.
  • Both hospitals employ specialist midwives targeting vulnerable women.
  • The Whittington has a dedicated teenage pregnancy team and the North Middlesex provides additional support for teenage parents – see teenage pregnancy section.
  • Antenatal and postnatal services are offered in the community via Children’s Centres in Haringey.
  • The Family Nurse Partnership has been operational in Haringey since October 2010 and supports first time mothers under the age of 20. See teenage pregnancy section
  • Pregnant women who smoke are referred to the Stop Smoking Service for support – see smoking section.
  • The Healthy Child Programme: Pregnancy and the first five years of life - Healthy Child Programme: pregnancy and the first five years of life (external link) provides a schedule of care for pregnant women. Haringey is currently an Early Implementer Site which will have a more intensive focus on health visiting and additional support for parents and parents to be.
  • Haringey Community Services are in the process of applying for UNICEF Baby Friendly accreditation to improve support for breastfeeding mothers. The Whittington Hospital has achieved Stage 2 accreditation - see the Baby Friendly website (external link) for more information.
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Projected service use in 3-5 years and 5-10 years

The rise in fertility rate and potential rise in birth rate over the next 3-5 years will impact on service provision. It is difficult to accurately predict projected service use as much will depend on national and local social and economic conditions.

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Expert opinion and evidence base

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Service users and carers opinion

  • There is a North London Maternity Services Liaison Committee where views of local women are shared with acute providers and commissioners to improve service delivery.
  • A project is underway in Haringey to promote early access to maternity services among the Somali community which will incorporate user views in delivery. This project arose following the findings from the Health Equity Audit.
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Unmet needs and service gaps

There are inequalities in terms of access to maternity services, with Black African women and under 20s least likely to book within the recommended time frame.

Breastfeeding rates are lower in the east of the borough and further work is needed to ensure equality of access to breastfeeding support services. As part of UNICEF Baby Friendly accreditation, targeted work will be planned in areas of lowest breastfeeding rates.

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Recommendations for Commissioning

  • Increase awareness of early booking targeting those areas and communities where late booking is highest.
  • Delivery of UNICEF Baby Friendly Action Plan to support women in the east of the borough to initiate and maintain breastfeeding.
  • Implement plans to ensure that services are targeted at the most vulnerable groups in Haringey
  • Implement the Healthy Child Programme and evaluate the impact of the Early Implementer Site in Haringey.
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Recommendations for further needs assessments

Annual Health Equity Audit on access to maternity services

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Key Contact

Sheena Carr, Senior Public Health Strategist, NHS North Central London/Haringey Council
sheena.carr@haringey.gov.uk

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Footnotes

  1. Promotion of breastfeeding initiation and duration (PDF 234kb external link)
  2. Health Equity Audit 2011 available from the Public Health Department, Haringey Council
  3. Review of the health inequalities infant mortality PSA target (external link)
  4. Unicef breastfeeding research - An overview (external link)
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Page Last Updated: 24 April 2013

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