- Key issues and gaps
- Who is at risk and why
- The level of need in the population
- Current services in relation to need
- Projected service use in 3-5 years and 5-10 years
- Expert opinion and evidence base
- Service users and carers opinion
- Unmet needs and service gaps
- Recommendations for consideration by commissioners
- Recommendations for further needs assessments
- Key contact
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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).
- 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
- 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
- Maternal death is extremely rare. The latest data available 2008–2010, reveals that 136 women in England and Wales died directly or indirectly related to pregnancy. The overall maternal mortality rate was 0.41 per 100,000 women aged 15-44. In London, there were 37 deaths in 2008-10, with a rate of 0.62 per 100,000 women aged 15-44. There were no maternal deaths in Haringey in that period. 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.
- 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 2011, the general fertility rate for Haringey was 64.8 compared to 83.5 in 2010, showing a significant decline (see figure below), although it should be noted that this decline is not reflected in a large decline in number of births (see birth rate section)
- The fertility rate in England in 2011 was 64.2 and 66.5 in London for the same period.
Figure 1: Fertility rate in Haringey, London and England 2002-2011
- The number of live births in Haringey in 2011 was 4,227, down from 4,456 in 2010
- The highest number of births is in wards in the east of the borough.
Low birth weight:
- In 2011, the proportion of births classified as a low birth weight birth was 8.1% in Haringey compared to 7.4% in England and 8.0% in London. The percentage of low birth weight has increased from 7.4% in 2010.
- Wards in the east of Haringey tend to have higher proportion of low birth weight babies.
Figure 2: Low birth weight trend in Haringey, London and England.
Source: ONS 1997 to 2011
Figure 3: Low birth weight by Haringey wards 2010-12
Source: ONS Public Health birth files 2010-2012
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.
An annual audit of booking data from the North Middlesex Hospital and Whittington Hospital is undertaken to assess if inequities exist for women accessing maternity services. Data is analysed by age, ethnicity, deprivation, ward and hospital. Gestation at booking is divided into three categories: early (under 13 weeks); late (between 13 and 22 weeks) and very late (over 22 weeks). The chart below describes antenatal bookings (the first appointment with the midwife) by gestation and age of mother in 2012 in Haringey.
- Overall, 67.4% of women booked within the recommended timeframe (69% in 2011, therefore showing a slight decline in early booking in 2012) however there are differences between age groups.
- Only 48.4% (n=60) of women aged under 20 booked early, slightly lower than in 2011 when 50% booked early.
- The highest proportion of women who booked early were those aged between 35-39 (64% n=426), but this is lower than in 2011 when 74% of this age group booked early.
Figure 4: Antenatal bookings by gestation and age of mother 2012
Source: Whittington Hospital and North Middlesex Hospital Maternity Information Systems
There are also variations in terms of ethnicity. As numbers of women from some ethnic groups who booked are very small, this might distort the findings and present a false picture. Therefore, for the purposes of this report analysis will focus on the largest ethnic groups in Haringey accessing antenatal services in 2011: Any Other White, White British; Any Other Ethnic Group, Black African and Black Caribbean respectively. Whilst the proportion of White British women who book early is 83.4%, the proportion of Black African women booking within the same time period is 57.2%. This has remained relatively unchanged from 2011.
Figure 5: Access by ethnicity 2012
Source: North Middlesex Hospital and Whittington Hospital Maternity Information Systems
The ethnic classifications Black African, Any Other White and Any Other Ethnic Group encompass a range of different nationalities and cultures. However, for women booking at the North Middlesex Hospital in 2012 it has been possible to break down the Black African, Any Other White and Any Other Ethnic Group classifications by country of birth. This has provided a more detailed analysis of ethnicity data.
Ethnicity broken down by country of birth was unavailable for the Whittington Hospital. This chapter focuses in particularly on the breakdown by country of birth for Black African women as additional work has been undertaken to understand barriers to booking early for these women.
In 2012, 281 out of the 1639 women who booked for antenatal care at the North Middlesex Hospital classified their ethnicity as Black African. The highest numbers of women came from Somalia (n=91) Ghana (n=80), Nigeria (n= 65), and the Congo (n=39).
Figure 6 describes antenatal booking by country of birth for Black African women. The proportion of women booking early ranged from 44% for women from Somalia to 58% for women from Ghana. However, women from all these countries are booking later than White British women.
Overall, 56% of women from Somalia and 51% of women from the Congo booked late. Congolese women were the most likely to book very late, 21%.
Figure 6: Antenatal booking by country of birth (Black African) 2012
Source: North Middlesex Hospital
Similarly, the White Other ethnic classification was broken down by country of birth. In 2012, 394 out of the 1639 women who booked for antenatal care at the North Middlesex Hospital classified their ethnicity as Any Other White. The highest numbers of women came from Poland (n= 165), Turkey (n=160), Romania (n=144) and Bulgaria (n=111). The number of women from Romania and Bulgaria booking for antenatal care at the North Middlesex Hospital in 2012 has almost doubled from 2011.
Figure 6 describes antenatal booking by country of birth for women who classified themselves as Any Other White. The proportion of women booking early ranged from 48% for women from Bulgaria to 61% for women from Turkey. However, women from all these countries are booking later than White British women.
Overall, 52% of women from Bulgaria and 51% of women from Romania booked late. Women from Romania were the most likely to book very late, 29%.
Figure 7: Antenatal booking by country of birth – White Other
Source: North Middlesex Hospital
There has been little improvement from 2011 in terms of women from Black African and White Other ethnic groups and further work is necessary to target these groups. Work is already underway to understand the barriers faced by Black African women (see separate report – Black African women, faith and early booking and the accompanying seminar report from January 2013). The chart below shows that those women living in the most deprived areas of Haringey are least likely to book early for antenatal care.
Figure 8: Access by Deprivation 2012
Source: North Middlesex and Whittington Hospitals
Figure 9 below describes access by hospital. While 79% of women accessing the Whittington booked early, only 55% of women booked at the North Middlesex did so. Similarly, 18% of women booked very late at the North Middlesex compared to 6% at the Whittington.
Figure 9: Access by Hospital 2012
Source: North Middlesex and Whittington Hospitals
Haringey’s performance on early maternity access is a cause for concern, particularly when compared to London and England. There are plans in place to improve performance
Figure 10: Trend in early access to maternity services for Haringey compared to London and England 2009/10-2012/13
Source: Department of Health
Infant Health – see infant mortality section of JSNA
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 statistical neighbours.
Figure 11: Breastfeeding initiation comparing Haringey with London, England and statistical neighbours 2010-2012
Source: Department of Health Integrated Performance Measure Return, 2013
In London, the uptake of breastfeeding is considerably higher compared to rates in England as a whole. Haringey’s initiation rate is higher than London and also higher than each of the statistical neighbours.
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 12: Breastfeeding at 6-8 weeks by ward 2012/13
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 13: Smoking during pregnancy in Haringey and statistical neighbours, London and England 2006/07-2012/13.
Source: ONS VS2 files 2006-2013
- 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:
- 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
- The majority of women in Haringey access maternity services from either the North Middlesex Hospital or the Whittington Hospital.
- Maternity services are commissioned by the Clinical Commissioning Group and there are opportunities to influence contracts to improve service delivery.
- 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.
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.
- ‘Fair Society Healthy Lives’ (The Marmot Review) (external link)
- Maternity Matters (Department of Health 2007) Maternity Matters: Choice, access and continuity of care in a safe service (external link)
- National Service Framework for Children, Young People and Maternity Services (DH 2004) National service framework for children, young people and maternity services: Core standards (external link)
- CG62 Antenatal care: full guideline (corrected June 2008) (external link)
- CG110 Pregnancy and complex social factors: full guideline (external link)
- Additional NICE Guidance on Smoking and Obesity see the NICE website (external link) for more information.
- The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer 2003-2005.
- The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. Centre for Maternal and Child Enquiries (CMACE).
- Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.
- Department of Health. Maternity Matters: Choice, access and continuity of care in a safe service. London: Department of Health; 2007.
- Confidential Enquiry into Maternal and Child Health (CEMACH). Perinatal Mortality 2007. London: CEMACH; 2009.
- Management of women with obesity in pregnancy Management of women with obesity in pregnancy (external link) CMACE/RCOG March 2010.
- QS37 NICE Guidance on postnatal care - July 2013 (External link)
- 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 research project with Black African communities exploring barriers to early maternity access was commissioned in Haringey in 2012. Report available from Public Health. A follow up seminar was held in January 2013 exploring issues of faith in relation to early booking. This report is also available from Public Health.
- A breastfeeding research project is currently underway in Haringey exploring why women choose to breastfeed or not, barriers to sustaining breastfeeding and exploring support options for those women who wish to breastfeed.
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.
- Increase awareness of early booking targeting those areas and communities where late booking is highest. Utilise community health champions; raise awareness of groups who book late with GPs, community and voluntary organisations, Children’s Centres and hospitals to proactively target these groups.
- 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.
Annual Health Equity Audit on access to maternity services
Sheena Carr, Senior Public Health Strategist, NHS North Central London/Haringey Council:
- Email: email@example.com
- Postnatal care overview
- Health Equity Audit 2011 available from the Public Health Department, Haringey Council
- Review of the health inequalities infant mortality PSA target (external link)
- Unicef breastfeeding research - An overview (external link)
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