Healthy Pregnancy

Why pregnancy is an important period

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.¹³

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.

What is the local picture?

The most recently compiled and published data, with comparison to other local authorities of similar deprivation, unless stated otherwise, as of April 2021.¹⁴

Healthy Pregnancy Indicator	Previous period [Comparator IMD 2019] (Date)	Most recent available period [Comparator IMD 2019] (Date)
Smoking at time of delivery (%)
	13.3 [NA] (2018/19)	12.0 [8.7] (2019/20)
Under 18s conception (Rate per 1,000)
	18.4 [13.8] (2018)	13.8 [NA] (2019)
Under 16s conception (Rate per 1,000))
	1.8 [1.6] (2018)	2.3 [NA] (2019)
Infant mortality rate up to 1 year (Rate per 1,000)
	5.2 [3.5] (2016-18)	4.4 [3.4] (2017-19)
Early access to maternity care (%)**
	NA [NA] (2017/18)	57.6 [54.5] (2018/19)

Milton Keynes’s overall score for deprivation (using the 2019 Index of Multiple Deprivation) relative to all other local authorities in England, puts it in the 3rd least deprived decile. Throughout this report, Milton Keynes performance is compared to other areas of similar deprivation where possible. For comparison to other local authorities of similar deprivation (IMD 2015), please refer to the reference.¹⁷

Table 1: Healthy pregnancy indictors as of July 2021 Sources:
Public Health Outcomes Framework. Section 1 (IMD 2019) [online] Available at https://fingertips.phe.org.uk/indicatorlist/view/tWhIbQL5J0#page/0/gid/1/pat/10113/par/cat-113-8/ati/202/are/E06000042/iid/93085/age/1/sex/2/cid/1/tbm/1 [Accessed 26 July 2021].

Public Health Outcome Framework. 2018. Public Health Profiles – PHE. [online] Available at: https://fingertips.phe.org.uk/search/early%20access#page/0/gid/1/pat/10113/par/cat-113-8/ati/302/are/E06000042/iid/93583/age/-1/sex/2/cid/1/tbm/1/page-options/car-do-0 [Accessed 12 August 2021]

Office of National Statistics. 2019. Conceptions in England and Wales – Office for National Statistics. [online] Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/
datasets/conceptionstatisticsenglandandwalesreferencetables [Accessed 12 August 2021]

*Percentage of pregnant women who have their booking appointment with a midwife within 10 completed weeks of their pregnancy

Over the last 10 years, there has been significant progress on teenage pregnancy with the under-18 and under-16 conception rates having both fallen by about 58%. However, Smoking at time of delivery is significantly higher when compared with similar local authorities in the same deprivation decile.

Infant mortality

There are approximately 3,500 live births in Milton Keynes each year, and about 12 babies die each year before their first birthday.18 The infant mortality rate in Milton Keynes (4.4 deaths per 1,000) is currently similar to other local authorities in the same deprivation decile (3.4 deaths per 1,000 live births).

During 2019/20, there were 15 child death notifications, a decrease from 30 in 2018/19. Of these, 4 were in infants aged 0-28 days, and 5 were infants aged 28-365 days old. Further analysis of these infant deaths indicates a disproportionately high number of deaths in babies born to mothers from black and minority ethnic groups, compared to babies born to mothers of all other ethnic groups in Milton Keynes

The Child Death Board has taken forward recommendations from its previous Annual Report. This includes continuing to work with services in the local Integrated Care System (ICS) covering Milton Keynes to enable shared learning from child death reviews; strengthening the focus on identifying modifiable factors and addressing them; undertaking a premature mortality review; and reviewing the effectiveness of the palliative care pathway. Recent improvements have included greater consistency and standards for paediatric palliative care, addressing co-sleeping via a campaign, and workshops across services to help raise awareness of consanguinity (e.g. a couple who are relatives by blood or have shared ancestry).

What will the board do next?

Continue to ensure a focus on identifying and addressing modifiable factors arising during reviews, including consanguinity
Continue to ensure information about any child deaths reviewed that meet the criteria for LeDeR (Learning Disability Mortality Review Programme) are reported to and shared with LeDeR
Monitor the palliative care pathway and promote support to bereaved families
Embed the use of the eCDOP system across the Milton Keynes workforce
Review and take forward recommendations from the extreme prematurity report

Easy 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 give advice and offer interventions to support a healthy pregnancy, including weight management during and after pregnancy and support to stop smoking. Currently seven out of ten women access a midwife before 10 weeks.

Ensuring early access to a midwife, preferably by week 10 of pregnancy will equip women with the knowledge and skills they need to modify the preventable risks to their pregnancy. A Cochrane review¹⁹ 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 as follows:

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 for childbearing women and their partners and families also means emotional, psychological, and social safety. This holistic sense of safety is supported through continuity models of care.

Locally, maternity services prioritise geographical areas in Milton Keynes where there are high levels of deprivation, and where women from ethnic minorities live. This targeted approach is proportionate to the level of disadvantage.

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 ensure that their voices are heard. Women need to be equal partners in their care and their choices respected. Local maternity services are currently implementing a co-produced Personalised Maternity Journey document to help facilitate this.

In addition, local maternity services are in the process of implementing the ‘Saving Babies’ Lives Care Bundle’²⁰ – a set of guidelines for reducing stillbirth. This includes conducting risk assessments throughout pregnancy and improvements in monitoring foetal wellbeing, with a named obstetrician who has early involvement and input into management plans for women with complex pregnancies.

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.²¹ It also increases the risk of complications in pregnancy and of the child developing several conditions later in life.

Babies living in areas of deprivation are more likely to be born to mothers who smoke, and this is contributing to the gap in health inequalities.²² Children born to parents who smoke are also more likely to become smokers themselves, which further perpetuates this inequality. In 2019-20, 12% of women in the catchment area of NHS Milton Keynes Clinical Commissioning Group were smoking at time of delivery²³ and around one in seven babies (15.1%) were living in a household with a smoker.²⁴

Early identification and effective referral pathways for pregnant women, and their partners to the Stop Smoking Service is vital for producing the best outcomes.²⁵ Where pregnant women or their partners smoke, they are referred to the local Stop Smoking Service for specialist support: www.thestopsmokingservice.co.uk.

Referrals to the ‘Stop Smoking Service’
The stop smoking referral system is an opt-out system for pregnant women. Between April 2019 and March 2020, 222 pregnant women across Milton Keynes were referred to the service for support.

Smokers choosing to opt out of support are still managed on a smokers’ pathway for antenatal care, which ensures:

All women have carbon monoxide (CO) monitoring at booking to determine whether they smoke and again at 36 weeks
Smokers and those with a CO of >4 ppm are referred to the Stop Smoking Service
Midwives discuss the implications of smoking during pregnancy
Smokers are referred for consultant-led care and have serial growth scans from 32 weeks and 4-weekly until delivery
Smokers and those with a CO >4 ppm have CO monitoring at every antenatal appointment

The COVID-19 pandemic has led to a reduction in the number of referrals (e.g. between April 20 and March 21 when compared to the previous year). To address this, a virtual training programme has been rolled out to all midwifery staff to ensure that pregnant women who smoke continue to be referred into the service at the earliest possible opportunity

Maternal obesity

Maternal obesity is defined as having a Body Mass Index (BMI) of 30kg/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.²⁶

Pregnant women who are obese are at increased risk of:

Having a stillbirth
Raised blood pressure and preeclampsia
Having a large baby or ill baby that needs monitoring
Developing gestational diabetes
Having a blood clot in the legs
Having a caesarean section

Maternal obesity has also been linked to chronic health conditions in children (including asthma and diabetes), and overweight and obesity in childhood. Among adults, 16 and over, 60% of women are overweight or obese.²⁷

During pregnancy, diet and exercise interventions can help 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. Pregnant women are referred to the local weight management service in Milton Keynes: More Life.
For further details, see www.more-life.co.uk

Teenage parents

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, which is trusted by young parents and focuses on building their skills, confidence and aspirations.

Mothers under 20 years of age are:²⁸

Three times more likely to smoke throughout pregnancy
50% less likely to breastfeed at 6 to 8 weeks
At higher risk of postnatal depression and poor mental health for up to three years after a birth
22% more likely to be living in poverty at age 30 and less likely to be employed or living with a partner
22% 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:

21% higher risk of a low birth weight
56% higher risk of infant mortality

In addition, young fathers are more likely to have poor education and have a greater risk of being unemployed in adult life.

The work of Midwifery, Health Visiting & School Nursing Teams is underpinned by a range of guidance to support vulnerable young parents. This includes Milton Keynes Inter-Agency Safeguarding guidance and supporting multiagency guidance for vulnerable families.²⁹ The guidance supports work from the disclosure of pregnancy and offers young parents a range of support to improve outcomes for themselves, their partner, and their child.

Maternal mental health

During the perinatal period (pregnancy and the first year following a birth), women are at risk of developing a first episode of mental illness with more than 1 in 10 women affected. Poor maternal mental health has important consequences for the infant’s health at birth, and the child’s health, emotional, behavioural and learning outcomes. This includes the negative influence on the mother’s ability to bond with her baby and subsequently the baby’s ability to develop a secure attachment.

The ability to identify risk factors and the symptoms can help with early identification, and timely support and treatment to minimise the impact on the mother, child and family. Maternal depression is also the strongest predictor of paternal depression, which is estimated at 4% during the first year after birth.³⁰

Key government investment into local perinatal mental health services has supported the local identification of gaps in current care provision and led to the development of integrated pathways of care. This has resulted in an increase in specialist mental health care from 12-24 months, improved access to psychological therapies and mental health checks for partners. The co-production of maternity outreach services are in development, for women with associated loss and trauma. This will include birth trauma, post-traumatic stress disorder (PTSD) following perinatal loss, parental separation, and severe fear of childbirth.

The impact of COVID-19 on healthy pregnacy

Whilst pregnancy can alter the body’s immune system and response to viral infections occasionally causing more severe symptoms, there is currently no evidence that pregnant women have an increased risk of severe disease due to COVID-19 or that there is a risk to their new-born babies.

However, in response to the data which indicates that ethnic minority communities are disproportionally affected by COVID-19, local maternity services have implemented the challenge set by the National Chief Midwifery Officer, Professor Jaqueline Dunkley-Bent, to implement four key areas to help address these inequalities:

Co-produced operational policy & implementation to manage the risks of COVID-19 for ethnic minority communities and at-risk pregnant women
Co-produced tailored communication to reassure ethnic minority communities women to seek help if they have any concerns
Discussion of vitamins, supplements and nutrition in pregnancy to be routinely given
Record data on maternity information systems

During the first wave of COVID-19 in early 2020, there were changes to the antenatal pathway, which included the replacement of face-to-face consultations with virtual consultations. This was to assist women practising social distancing measures and reduce the risk of transmission between women, staff and other clinics visitors. Greater attendance by parents has been noted for some virtual health visitor appointments.

Those appointments requiring face-to-face antenatal care were provided in children and family centres encouraging collaborative working across services. A co-produced ‘stepping stones’- pictogram was published widely on social media to help families navigate the changes to services made during the COVID-19 pandemic.

Antenatal educational classes are now carried out virtually, and greater attendance by parents has been noted for these, and for some virtual health visitor appointments. A challenging consequence of the changes to antenatal services has been the increase in loneliness and isolation, with vulnerable mothers being able to ‘mask’ their mental health symptoms. Maternity services and staff have also highlighted increased maternal anxiety due to changes in how antenatal support and education are delivered.³¹

Priority areas we should continue to build on:

Promote early access to maternity care (by 10 weeks) and monitor where mothers are presenting later to identify if there are any additional needs.
Embed a ‘Think Family’ approach to identify and support needs, and ensure services encompass partners and significant adults within the family.
Transform and improve local maternity services in line with Better Births32 drivers; ensure services continue to be co-produced locally, and that maternity safety champions are represented at trust board level.

Priority actions to deliver better outcomes:

Roll-out ‘Continuity of Carer’ for all women, to address many of the pre-existing health inequalities – and reduce the likelihood of mums having preterm births, losing their baby in pregnancy or in the first month following birth.
All Milton Keynes services throughout the maternity journey should listen to women and their partners, ensure their voices are heard, and respect their informed choices, by personalising their care.
Improve information sharing systems between maternity and health visiting services to ensure prompt access to the full Healthy Child Programme.
Develop and co-produce maternal mental health services associated with grief, loss and trauma to meet the current gap in provision.
Review the effectiveness and impact of the parental mental health pathway – with a particular focus on ethnic minority families – to address mental illness during the perinatal period.
Ensure services for parents and carers are personalised and are able to provide choices for how they access support, including both face to face and virtual provision
Develop and monitor a training programme to improve skills of service providers to provide a more effective tailored approach to supporting women with reducing tobacco dependence.
Ensure effective measurement and recording of BMI, and referral to appropriate weight management services both antenatal and postnatal as identified in the Maternal Obesity Pathway.

References

Children’s Commissioner for England. 2019. Childhood vulnerability in England in 2019. [online] Available at: https://www.childrenscommissioner.gov.uk/publication/childhood-vulnerability-in-england-2019 [Accessed 25 January 2021].
Public Health Outcomes Framework. Section 1 (IMD 2019) [online] Available at https://fingertips.phe.org.uk/indicator-list/view/tWhIbQL5J0#page/0/gid/1/pat/10113/par/cat-113-8/ati/202/are/E06000042/iid/93085/age/1/sex/2/cid/1/tbm/1 [Accessed 26 July 2021].
Office of National Statistics. 2019. Conceptions in England and Wales – Office for National Statistics. [online] Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/datasets/conceptionstatisticsenglandandwalesreferencetables
[Accessed 12 August 2021].
Public Health Outcome Framework. 2018. Public Health Profiles – PHE. [online] Available at: https://fingertips.phe.org.uk/search/early%20access#page/0/gid/1/pat/10113/par/cat-113-8/ati/302/are/E06000042/iid/93583/age/-1/sex/2/cid/1/tbm/1/page-options/car-do-0 [Accessed 12 August 2021].
Public Health Outcomes Framework: CYP JSNA – Section 1 (IMD 2015): https://fingertips.phe.org.uk/indicator-list/view/tWhIbQL5J0#page/0/gid/1/pat/10105/ati/202/are/E06000042/iid/93085/age/1/sex/2/cat/-1/ctp/-1/yrr/1/cid/1/tbm/1 [Accessed 14 January 2021].
Office for National Statistics. 2019. Births In England And Wales: Summary Tables – Office For National Statistics. [online] Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/datasets/birthsummarytables [Accessed 21 December 2020].
Sandall, J., Soltani, H., Shennan, A. and Devane, D., 2019. [online] Available at: Implementing midwife-led continuity models of care and what do we still need to find out? – Evidently Cochrane. [online] Evidently Cochrane. Available at: https://www.evidentlycochrane.net/midwife-led-continuity-of-care/ [Accessed 1 February 2021].
NHS England, Saving Babies Lives Car Bundle Version 2. [online] Available at: https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babieslives-care-bundle-version-two-v5.pdf [Accessed 12 May 2021].
Royal Society for Public Health. 2013. RSPH Part of the Smoking in Pregnancy Challenge Group Calling for Carbon Monoxide Screening in Pregnancy. [online] Available at: https://www.rsph.org.uk/about-us/news/rsph-part-of-the-smoking-in-pregnancy-challenge-group-calling-for-carbon-monoxide-screeningin-pregnancy.html [Accessed 8 February 2021].
PHE, 2019. Health Of Women Before And During Pregnancy: Health Behaviours, Risk Factors And Inequalities. [online] Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/844210/Health_of_women_before_and_during_pregnancy_2019.pdf [Accessed 4 November 2020].
PHE, 2020. Local Tobacco Control Profiles – PHE. [online] Available at: https://fingertips.phe.org.uk/profile/tobacco-control/data#page/3/gid/1938132885/pat/6/par/E12000008/ati/102/are/E06000036/iid/92443/age/168/sex/4/cid/4/tbm/1/page-options/ovw-do-0_car-do-0 [Accessed 4 November 2020].
24 PHE, 2020. Local Tobacco Control Profiles – PHE. [online] Available at: https://fingertips.phe.org.uk/profile/tobacco-control/data#page/0/gid/1938132885/pat/10113/ati/302/are/E06000042/iid/92443/age/168/sex/4/cid/1/tbm/1/page-options/ovw-do-0_car-do-0 [Accessed 4 November 2020].
Public Health England, 2020. Local Tobacco Control Profiles – PHE. [online] Available at: https://fingertips.phe.org.uk/profile/tobacco-control/data#page/0/gid/1938132885/pat/10113/ati/302/are/E06000042/iid/92443/age/168/sex/4/cid/1/tbm/1/page-options/ovw-do-0_car-do-0 [Accessed 4 November 2020].
Public Health England (2015). Maternal obesity. [online] Available at: https://www.activematters.org/phe-maternal-obesity/ [Accessed 26 July 2021].
NHS Digital. 2018. Health Survey For England – NHS Digital. [online] Available at: https://digital.nhs.uk/data-and-information/publications/statistical/healthsurvey-for-england [Accessed 13 January 2021].
Department for Children, Schools and Families and Department for Health (2010). Teenage Pregnancy Strategy: Beyond 2010.
MK Together. 2020. MK Levels of Need | Milton Keynes Inter-Agency Safeguarding Children. [online] Available at: https://mkscb.procedures.org.uk/ykyxsq/assessing-need-and-providing-help/mk-levels-of-need [Accessed 14 May 2021].
Davé, S., Petersen, I., Sherr, L. and Nazareth, I., 2010. Incidence of Maternal and Paternal Depression in Primary Care. Archives of Paediatrics & Adolescent Medicine.
The Impact of the COVID-19 upon Children, Young People & Expectant Mothers: Phase 1, Hasna Dulfeker, Bedford, 2020.
NHS England. 2017. BETTER BIRTHS Improving outcomes of maternity services in England. [online] Available at: https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf?PDFPATHWAY=PDF [Accessed 12 March 2021].

JSNA Sections