Antenatal pathway

A care pathway describes what a person’s journey of care should look like - what care they should receive, when they should receive it and when they should be referred for additional care and support. The pathway will outline routine care which all people should receive. There may also be additional pathways which only some people will go through in order to provide for any additional needs. Whatever the individual journey, the use of a care pathway should result in the same standard of care being provided to each individual.

The antenatal care pathway (National Institute for Health and Care Excellence) describes the journey of care which should be provided to all pregnant women. Additional pathways are outlined for women who have pre-existing health conditions or more complicated pregnancies.

Antenatal care provides an opportunity to screen for and prevent conditions in the unborn child which could lead to poor health outcomes. The National Antenatal Screening Programme provides a timeline for screening during pregnancy. It is also essential to maximise the health of the mother in pregnancy, which, as a recent global trial has shown, is a key indicator of healthy birth outcomes for the child.

UK Guidelines recommend that pregnant women should have their first antenatal appointment with a midwife in the first 12 weeks (before 13 weeks) of pregnancy.

What do we know?

Late access and poor access to antenatal care are risk factors for poor outcomes for both the mother and baby. Mothers may also not receive antenatal care if they are unaware of their pregnancy or are concealing a known pregnancy. These are also risk factors for poor outcome and, in the case of concealed pregnancies, may raise safeguarding concerns.

(Source: Hadrill et al 2014)

Delayed access to the antenatal pathway is particularly associated with low birth weight of babies. Low birth weight, in turn is associated with a higher rate of infant mortality as well as other risk factors for poor outcomes such as young age of mother and maternal smoking.

(Source: Preventing Low birth weight)

As highlighted by the 2012 report of the Confidential Enquiry into Maternal Deaths (CEMD), more than two thirds of women who die during or as a result of their pregnancy in the UK did not receive the nationally recommended level of antenatal care.

Facts, Figures, Trends

NHS England collects data from maternity service providers about the number of women who have accessed maternity services by the recommended 12 weeks and 6 days of pregnancy.

Figure 1 shows this data per quarter for women registered with GPs in Slough, though it must be noted that the method for calculating this proportion along with the highly mobile nature of the population in Slough means that this statistic may not always be accurate. The sharp dip in timely access in early 2014 recorded here is likely to be an anomalous result due to changes in recording methods as a similar pattern is seen in for Windsor and Maidenhead CCG.

Figure 1. Access to antenatal care before 13 weeks gestation Slough CCG

Figure 1

Low birth weight (when a baby weighs less than 2,500g) is a key indicator of health inequalities, and, as indicated above associated with delayed access to antenatal care. The Public Health Outcomes Framework measures the number of babies of at least 37 completed week’s gestation born at a low birth weight. Figure 2, below shows that though usually worse than the England average, the proportion of low birth weight term babies in Slough in 2014 was similar to the national average.

Figure 2: Low birth weight of term babies in Slough

Figure 2

When looking at all births, however (including still births and pre-term births) the rate of low birth weight in Slough was higher than the national average at 8.9% (Figure 3).

Figure 3. Low birthweight rate in Slough

Figure 3

(Source: Public Health Outcomes Framework)

A still birth audit for Thames Valley showed that Berkshire East rates were 5 per 1,000 births compared to the West of the county at 6.1 per 1,000 but the numbers used in the audit were small so may not be a reliable indicator of differences. Rates were not available at local authority or CCG level but recommendations included tackling the risk factors for still birth and infant death. These include: maternal age, maternal smoking, maternal obesity, socioeconomic position, multiple birth, and influenza.

A new contract for the delivery of flu vaccinations for pregnant women has increased uptake in 2014-15 (6.4% point change in uptake). Unfortunately, data for antenatal screening coverage at local authority level is not available.

National & Local Strategies (Current best practices)

National

NICE Guidance
NICE guidance CG 110 which describes the additional care needed for vulnerable women over and above the standard antenatal pathway. See also NICE guidance on antenatal care CG62 (NICE, 2008) which contains partial updates for; PH56 Vitamin D: increasing supplement use among at-risk groups and CG192 Antenatal and postnatal mental health

Evidence Base
The GOV.UK site has the evidence base for the pregnancy and the first five years and also the recently published evidence based review of the Health Child Programme.

Best Practice
The National Antenatal Screening Programme provides a timeline for screening during pregnancy it includes the following:

  • Preconception eye screening for women with type 1 or 2 diabetes and again at 28 weeks
  • Midwives working within screening teams undertake blood tests to detect Sickle cell and Thalassaemia by 10 weeks
  • Blood tests and scans can detect selected congenital anomalies at 12 weeks (at the dating scan) and again at 18-20 weeks
  • Screening for infectious diseases is offered before 10 weeks and again at 28 weeks, if initially declined
  • Further screening of the new born child is done within the new born blood spot test (which should be taken within five days of the birth) and the physical examination (which has to take place within 72 hours of the birth)

The maternity care that every woman should receive as part of the antenatal care pathway is listed in the maternity section. The Healthy Child Programme is a programme of health and social care that should be received by all children age 0 to 5 years. It includes a detailed schedule for care during pregnancy. This schedule requires that the mother receives the following checks in pregnancy.

  • A full health and social care assessment of needs, risks and choices by 12 weeks of pregnancy by a midwife or maternity healthcare professional.
  • Notification to the child health programme team of prospective parents requiring additional early intervention and prevention
  • Routine antenatal care and screening for maternal infections, rubella susceptibility, blood disorders and foetal anomalies.
  • Health and lifestyle advice to include diet, weight control, physical activity, smoking, stress in pregnancy, alcohol, drug intake, etc.
  • Distribution of The Pregnancy Book to first-time parents; access to written/online information about, and preparation for, childbirth and parenting; distribution of antenatal screening leaflet.
  • Discussion on benefits of breastfeeding with prospective parents – and risks of not breastfeeding.
  • Introduction to resources, including children’s centres, Family Information Services, primary healthcare teams, and benefits and housing advice
  • Support for families whose first language is not English.

In addition, preparation for parenthood should begin early in pregnancy and include:

  • Information on services and choices, maternal/paternal rights and benefits, use of prescription drugs during pregnancy, dietary considerations, travel safety, maternal self-care, etc.
  • Social support using group-based antenatal classes in community or healthcare settings that respond to the priorities of parents and cover:
    • the transition to parenthood (particularly for first-time parents); relationship issues and preparation for new roles and responsibilities; the parent–infant relationship; problem-solving skills (based on programmes such as Preparation for Parenting, First Steps in Parenting, One Plus One);
    • the specific concerns of fathers, including advice about supporting their partner during pregnancy and labour, care of infants, emotional and practical preparation for fatherhood (particularly for first-time fathers);
    • discussion on breastfeeding using interactive group work and/or peer support programmes; and standard health promotion

Local

Localised clinical interventions for the reduction of still births are as set out in the Thames Valley clinical network plan:

  • There is a need for further education of primary care and midwifery staff on features of pre conception and early pregnancy care highlighting the need for things such as aspirin, high dose folic acid, good diabetic care etc.
  • The measurement of fundal height should be standardised across Thames Valley and recorded at each antenatal visit.
  • Each Trust should consider whether women who are having serial scans should have either additional scans or the timing of routine scans altered such that late pregnancy is covered.
  • Every professional should be aware of the need for good communication and ensure a full history is available where a woman is moving between providers.
  • Each discharge summary after pregnancy should contain specific advice about the need for any special measures in any subsequent pregnancy and should be provided to the mother.
  • Each Trust should examine how post mortem consent is sought and by whom in order to improve the uptake of post mortem after stillbirth.

The Oxford Academic Health Sciences Network has identified two key areas for collaborative work: reducing stillbirths and preterm births

The clinical projects underway include:

  • Universal availability of screening results that can be used to screen for stillbirth
  • Universal fibronectin usage in threatened preterm labour
  • Universal prenatal diagnosis of placenta accrete (AIP)
  • Automated image quality analysis for anomaly scanning
  • Development of robotic remote ultrasound scanning
  • Early diagnosis of pre eclampsia
  • Rationalisation of preterm labour services
  • Screening for preterm labour

Vitamin D provision has been in place in East Berkshire since 2009 and this will continue.

What is this telling us?

It should be ensured that all women access the antenatal care pathway by the recommended stage of pregnancy in order to offer every women the same standard of care and support. This will make certain that this vital opportunity for screening and optimisation of a mother’s health during pregnancy is taken. It will provide opportunity for information sharing for all parents and it will allow for specialist support to be given to those who need it. Provision of additional midwifery support for vulnerable women via the Crystal team and the Family Nurse Partnership is good and data sharing has improved.

Key areas of work are collaborative working in order to reduce still births and preterm births. There are inequalities in the timeliness of accessing the antenatal care pathways and the occurrence of babies being born with a low birth weight or being still born. Tackling these inequalities is key to ensuring that all women are offered the best standard of care at that their babies are offered the best start in life.

What are the key inequalities?

NICE Guidance CG 110 on women who have complex social risk factors is clear. The vulnerabilities most commonly found with poor or delayed access to the antenatal pathway are in women who; speak English as a second language, are substance misusers, are new entrants or asylum seekers or who are suffering from domestic abuse and those who are first time mothers under the age of 20 years.

Observational studies, mostly from outside the UK, have suggested that ‘late bookers’ for antenatal care are typically from socially excluded groups; ethnicity in particular, but also young age, low income and educational level, lack of support and substance misuse have been found to be common characteristics in this group of women. (Source: Haddrill et al)

What are the unmet needs/ service gaps?

  • There is as yet no widespread antenatal prevention programme in place or a consistent offer of cervical screening within our main hospital providers across the Thames Valley.
  • There is a gap in population wide provision of healthy weight and smoking cessation advice to pregnant women which a pilot in 2015 aims to address.

Recommendations for consideration by other key organisations:

  • To implement the Oxford Academic Health Science Network recommendations to reduce the risk factors for preterm birth and for still birth.
  • For all hospital providers to offer carbon monoxide testing of smoking status antenatally: Wexham Park Hospital does not yet offer this.
  • For CCGs to commission data on perinatal mental health

See also