Every year in the UK over 6,500 babies die just before, during or soon after birth. While other countries have succeeding in reducing their rates of stillbirth, the UK’s the figure is still largely unchanged from a decade ago.
The following section is work in progress. NHS England intends to undertake further work, in partnership with PHE, to assess the priorities in relation to maternal and neonatal paediatric interventions during 2014/15.
- 8.1 Community based genetic counselling
- 8.2 Management of fetal growth restriction
- 8.3 Smoking cessation in pregnancy
- 8.4 Advice on maternal obesity
- 8.5 Maternal and perinatal mental health
- 8.6 Breastfeeding in neonatal units
- 8.7 Maternal mental health
Preconception and pre-pregnancy care
Issue: The rate of infant deaths in the Pakistani community is double the national average rate. The inequality gap is likely to be exacerbated by marriage customs in the Pakistani community which are known to include high rates of cousin marriages, which have been shown to result in higher rates of babies being born with genetic anomalies. 17 percent of all stillbirths (approximately 600 per year nationally) are caused by genetic anomalies.
Suggested Action: Commissioners may wish to consider investment in community-based health champions and communication campaigns aimed at raising awareness of the implications of genetic inheritance alongside community based access to genetic counselling and family planning services as well as enhanced diagnostic services. In extreme cases in-vitro fertilisation can be supported by pre-implantation embryo selection using a risk based genetic diagnosis (PIGD).
Further, consideration should be given to ensuring through contract specifications that antenatal and paediatric services notify any genetic anomalies identified to the local register of congenital anomalies. This includes those identified antenatal, following birth, during infancy and through childhood.
Issue: 39 percent of all stillbirths (approximately 1,400 per year nationally) are now known to be the result of fetal growth restriction (babies who are not growing as well as they should be in the womb). It is estimated that 800 of these could be saved every year, an overall reduction of stillbirth rates by 22 percent.
Suggested Action: Initiatives in the West Midlands supported by The Perinatal Institute, have shown a reduction in stillbirth rates through the improved antenatal identification of pregnancies which are at risk due to fetal growth problems. This includes increased monitoring of fetal growth by using customised growth charts, ultrasound scanning protocols towards the end of the pregnancy, escalation protocols to obstetric consultant care and in some cases the management of delivery up to two weeks early.
Issue: Smoking in pregnancy has a significant impact on avoidable mortality. It causes impaired fetal growth, low birth weight and pre-term birth as well as being associated with an increased risk of miscarriage, stillbirth, neonatal death and sudden infant death. Smoking in pregnancy is high in England at 12.7 percent with tenfold variation between local areas. Smoking is most prevalent in young, white, poorly educated expectant mothers from deprived communities.
Suggested Action: Consider joint action with local authorities to deliver behavioural change interventions during pregnancy, as there is evidence these can increase smoking cessation rates. Communications channels such as mobile phones and social media may be used to reach groups with highest smoking prevalence. The NICE guidance on smoking cessation for acute, maternity and mental health services was published on 27 November 2013. It gives greater detail about provision of services in these settings.
Issue: Pregnant women who are obese have greater chance of having first trimester miscarriage, developing gestational diabetes, pre-eclampsia, or experiencing thromboembolism during pregnancy. It is difficult to monitor the growth of the baby on obese women, who are also approximately twice as likely to have a stillborn baby as women with a healthy BMI, and children of obese mothers are at risk of later obesity themselves. Obesity is a feature of 35 percent of maternal deaths.
An observational study also provides evidence for maternal obesity being associated with delivery and outcomes complications such as induction of labour, caesarean section, postpartum haemorrhage, large babies suffering dislocated shoulders and admissions to neonatal units. In addition there are also increased difficulties associated with the management of the mother and baby during labour including anaesthetic issues (airway management, vascular access and regional techniques), difficulties with monitoring of the baby’s heartbeat and surgical access issues where a caesarean section is required.
Suggested Action: Weight management programmes during pregnancy can reduce weight gain during pregnancy – (note though that there are no trials relating to weight reduction during pregnancy and there is concern about the safety of such an approach).
Acceptable approaches are more likely to involve the limitation of weight gain during pregnancy, post pregnancy weight management counselling and more conventional weight management approaches between pregnancies.
Antenatal guidelines from the Royal College of Obstetrics and Gynaecology include provision for:
- measuring the height and weight of every woman at antenatal booking;
- providing women with information on the risks of obesity in pregnancy;
- assessing the anaesthetic risks for delivery;
- assessing the manual handling risks for delivery;
- assessing the risk of venous thromboembolism and advising on the use of prophylaxis as appropriate, either aspirin or low molecular weight heparin; and regular monitoring of blood pressure and blood sugar levels.
It will also be important to consider basic practical issues such as the maximum weight limits of trolleys, wheel chairs and other equipment as well as oversized cuffs to support the on-going monitoring of blood pressure during labour.
Issue: Maternal depression during pregnancy is also known to have an adverse impact on birth outcomes and also on continuing depression in the postnatal period. There is also an emerging body of evidenceto suggest that psychosocial stress during pregnancy can not only adversely influence pregnancy outcomes but predispose the child, through biological changes, to an increased risk of disease in later life.
Suggested Action: Consider using contracting levers to specify the need for providers to comply with NICE guidelines on antenatal and postnatal mental health. There is also emerging evidence that lay support during pregnancy and childbirth from a volunteer doula service can be effective and is highly valued by vulnerable, socially isolated women. Commissioners may wish to consider encouraging the provision of such support.
Issue: There are approximately 2,200 neonatal deaths every year. A significant number of these occur in neonatal units and are the result of pre-term births. Breastfeeding reduces infection rates and the rates of hospital admissions. These pre-term infants also have underdeveloped digestive systems and as a result may succumb to necrotising enterocolitis, where the tissue of the bowel starts to die.
Suggested Action: Consider using contracting levers to systematically operationalize the approach to breastfeeding in neonatal units so that it becomes the norm. Best Beginnings have developed a comprehensive range of resources for both parents and professional as part of their Small Wonders programme. In addition a network of champions can run workshops aimed at ‘Getting it right from the start’ and make use of prescribed audit tool to drive service improvement. Further details are available on the Best Beginnings website.
Issue: Women with a history of serious mental health problems or indeed a family history of mental health disorders are at risk of post-partum psychosis or exacerbation of an existing condition. This is a serious mental health issue which can render the mother unable to adequately care for herself or her baby. This can result in an increased risk of suicide for the mother and a risk of poor development outcomes for the child.
Suggested Action: In a small number of extreme cases pregnant women and new mothers will need to be cared for via a network of specialised ‘mother and baby units’, where the mental health needs of mothers can be managed alongside the physical, social and emotional needs of the new infant. Commissioners may wish to ensure that appropriate capacity planning is undertaken.