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.
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.
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.
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.
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).
(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.
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
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.
The National Antenatal Screening Programme provides a timeline for screening during pregnancy it includes the following:
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.
In addition, preparation for parenthood should begin early in pregnancy and include:
Localised clinical interventions for the reduction of still births are as set out in the Thames Valley clinical network plan:
The Oxford Academic Health Sciences Network has identified two key areas for collaborative work: reducing stillbirths and preterm births
The clinical projects underway include:
Vitamin D provision has been in place in East Berkshire since 2009 and this will continue.
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.
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)