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Guideline calls for changes in practice to increase uptake of antenatal care for pregnant women in difficult social circumstances

Extra help for women including teenagers, those who misuse drugs, women who experience domestic abuse and those who find it difficult speaking or reading English

Too many women faced with difficult social circumstances are not accessing or engaging with maternity services with potential negative consequences for them and their baby's health. Now, a new NHS guideline published today (22 September) calls for the re-organisation of these services to improve access to and uptake of antenatal care for women in difficult social circumstances, thereby helping to prevent complications and potentially save the lives of these mothers and their babies.

Difficult social circumstances, or complex social factors, can include poverty, homelessness, unemployment, substance misuse, difficulty reading or speaking English, teenage pregnancy and domestic abuse. Pregnant women in these situations often do not attend antenatal appointments as traditional services are often not adequate for their needs. However, a lack of good antenatal care can increase the risk of women dying from complications during pregnancy or after birth, with women living in areas of high deprivation in England five times more likely to die during pregnancy or after childbirth than women in more affluent areas (from Confidential Enquiry into Maternal and Child Health (CEMACH) Saving Mothers' Lives 2003-2005: United Kingdom. CEMACH: London, 2007). Babies born into these circumstances are also around twice as likely to be stillborn or die shortly after birth as those who are not (from Confidential Enquiry into Maternal and Child Health (CEMACH) Perinatal Mortality 2007: United Kingdom. CEMACH: London, 2009).

The new guideline, developed by the National Institute for Health and Care Excellence (NICE) in close collaboration with the Social Care Institute for Excellence (SCIE), calls on antenatal services to become flexible and supportive. This includes the NHS working with social care providers and, in some cases charities and the police, where appropriate, in order to properly care for these vulnerable women. Its aim is to help encourage access to and uptake of effective care for pregnant women with complex social factors to ensure they and their babies are kept as safe and healthy during pregnancy as possible. The guideline highlights the following groups as examples of women who need particular, tailored support throughout their pregnancies although it provides guiding principles for care for all women whose pregnancies are complicated by difficult social circumstances;

  • Those aged under 20
  • Women who misuse substances
  • Women who experience domestic abuse
  • Pregnant women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English

Dr Gillian Leng, NICE Deputy Chief Executive, said: “Expectant mothers need support throughout their pregnancy yet some groups of women do not access, or continue to maintain contact with, traditional antenatal care services because of issues such as domestic violence, teenage pregnancy or not having English as a first language. They might feel scared, overwhelmed, judged, unable to communicate, or may be physically stopped from attending appointments. Although these women represent a small proportion of those having babies in the UK each year, they and their unborn children deserve the same level of care as anyone else.”

“This guideline will help midwives, GPs, obstetricians, commissioners and managers and other professionals who come into contact with these women across the NHS and social care to develop services that will improve access to care for these pregnant women, giving them better and effective support.”

Amanda Edwards, SCIE Deputy Chief Executive, said: “Social care providers can play an important part in the design of maternity services. It is important that women receive adequate, timely, flexible care that gives them the right support throughout pregnancy, so that they and their babies are kept safe and healthy. A multi-agency approach is an absolute necessity to make sure their needs are fully met.”

Commissioners play an important role in the design and delivery of services, yet antenatal care for these vulnerable groups of women can be unsuitable, inflexible and judgmental. The guideline makes recommendations to help commissioners ensure services are fit for purpose, including:

  • Recording information on the numbers of women with complex social factors attending antenatal care to ensure services are organised in the most effective manner.
  • Working with relevant local agencies, including social care and voluntary services to co-ordinate antenatal care for women who misuse substances
  • Providing information about pregnancy and antenatal services in a variety of formats, settings and languages for women who are recent migrants or for whom English is not their first language
  • Consider commissioning a specialist antenatal service for young women under the age of 20. This could include antenatal care and education in peer groups in different locations (e.g. schools, colleges, GP surgeries) or offering peer group support at the same time as antenatal appointments in a one-stop shop where a range of services can be accessed at the same time, offering a named midwife, who should take responsibility for and provide the majority of the woman's antenatal care, and provide a direct phone number for the midwife.
  • Supporting women who experience domestic abuse by ensuring that a local protocol is developed jointly with social care providers, the police and voluntary agencies and that it is written by a healthcare professional with expertise in the care of women experiencing domestic abuse
  • Asking women from how services can be improved

Rhona Hughes, Lead Obstetrician at NHS Lothian and Chair of the Guideline Development Group (GDG), said: “Commissioners of health and social care services will play a vital role in making sure mums-to-be with complex social factors get the right kind of support. However, the difficulty they face is that traditional services often do not provide these women with the right type of support, which is why many women with complex social factors do not access antenatal services in the first place. This makes it difficult to know how services need to change to best serve their local population.

“The first step will be to record information from those women with complex social factors who do access services as this will be the best way to learn how services need to adapt. Working with other agencies and organisations will also be important to ensure flexibility in services and make sure women have a co-ordinated care plan to give them the best standard of care possible.”

The guideline also targets GPs, midwives, obstetricians and other healthcare professionals involved in antenatal care, making practical recommendations to make women with complex social factors feel safer, better understood and reassured. These include:

  • Give women with complex social factors a telephone number to contact a healthcare professional outside of normal working hours, at their booking appointment
  • Provide women with a private one-to-one consultation on at least one occasion to facilitate discussion of sensitive issues
  • Use a variety of methods (e.g. text messages) to remind women who misuse substances of upcoming and missed antenatal appointments
  • For women who have difficulty speaking or reading English, provide them with an interpreter (not a member of their family, legal guardian or partner) who can communicate with them in their preferred language

Yana Richens, Consultant Midwife for University College London Hospitals NHS Foundation Trust and guideline developer, said: “There will be inevitable challenges for midwives in putting these recommendations into practice, but I passionately believe this guideline will make a real difference to the care of pregnant women with complex social factors. It is unacceptable that mums and babies are still dying in this country because of a lack of contact with antenatal care. We need to do everything we can to help and support these women to ensure they - and ultimately their babies - survive and are safe and healthy.”

Sarah Fishburn, who runs the Pelvic Partnership Charity, supports women with complex social factors. She helped to develop the guideline and said: “I represent and help look after pregnant women through a variety of ways including peer support. I became interested in helping women with complex social factors after meeting women in my local area who were experiencing domestic abuse and I couldn't believe how difficult it was to help them access services. I also became aware of how many women do not fit into the glossy magazine picture of a pregnant woman and how challenging this can be both for the women involved and for those caring for them. This guideline should enable services to develop flexibility as well as specialist care, which is what these groups of women need.”

Professor Sir Sabaratnam Arulkumaran, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said: “Personal circumstances such social deprivation, substance misuse and domestic abuse may complicate an otherwise healthy pregnancy.

“At-risk pregnancies need to be identified and the involvement of the GP at least once in early pregnancy is useful. GPs have information about the woman's medical history, including the complex social issues she may face. With the woman's consent, such information should then be shared with the obstetrician and midwife so that tailored care can be provided in a sensitive and caring manner.

“This new guideline provides us with guidance on the appropriate care of such women. Working closely with social services, the NICE recommendations will help doctors provide the extra support that these vulnerable women need.”

Jane Brewin, Chief Executive of the baby charity Tommy's, said: “Women with complex needs have a deplorably high risk of experiencing pregnancy problems.

“Any barrier that prevents a pregnant woman from getting the care that both she and her baby need, be it substance misuse, being a teenager, not speaking English, domestic abuse, homelessness or anything else, poses a preventable risk to both mum and baby. Making maternity services both accessible and able to meet the often complex needs of these women is vital in mitigating these circumstances and helping their babies be born healthy.”

Mary Newburn, Head of Research and Information at NCT, the UK's largest parenting charity, said: “If implemented, this guidance has real potential to make maternity services more effective in reducing health inequalities. It provides clear recommendations to make maternity care more accessible and responsive to the complex needs of vulnerable women who can often slip through the net. NCT particularly supports the emphasis on multi-agency working to ensure holistic care provision and improve the health and wellbeing of vulnerable pregnant women, their partners and children.”

This is the latest in a series of guidance produced by NICE that aims to reduce complications in pregnancy Other, recently published guidance in this series includes guidelines for healthcare professionals on preventing, diagnosing and managing hypertension (high blood pressure) in pregnancy and public health guidance on quitting smoking in pregnancy and following childbirth and also weight management before, during and after pregnancy.

Ends

Notes to Editors

Key recommendations to raise standards of care for...

Pregnant women who misuse substances

  • Working with local agencies, including social care and voluntary organisations that provide substance misuse services, to coordinate antenatal care
  • Offer referral to an appropriate substance misuse programme, the first time a woman who misuses substances discloses that she is pregnant
  • Offer each woman a named midwife or doctor who has specialised knowledge of, and experience in, the care of women who misuse substances, and provide a direct phone number for the named midwife or doctor
  • Working with social care professionals to provide supportive and coordinated care
  • Training for healthcare professionals on the social and psychological needs of women who misuse substances. They should also be given training on how to communicate sensitively with women who misuse substances, as should non-clinical staff such as receptionists

Pregnant women who experience domestic abuse

  • Supporting women who experience domestic abuse by ensuring that a local protocol is developed jointly with social care providers, the police and voluntary agencies and that it is written by a healthcare professional with expertise in the care of women experiencing domestic abuse
  • Providing for flexibility in the length and frequency of antenatal appointments, to allow more time for women to discuss the domestic abuse they are experiencing
  • Offering the woman a named midwife, who should take responsibility for and provide the majority of her antenatal care
  • Joint training for health and social care professionals to facilitate greater understanding of each other's roles and enable healthcare professionals to inform and reassure women who are apprehensive about the involvement of social services.
  • Tell the woman that the information she discloses will be kept in a confidential record and will not be included in her handheld antenatal record and consider offering her a domestic abuse support worker.

Pregnant women who have difficulty speaking or reading English

  • Working with local agencies that provide housing and other services for recent migrants, asylum seekers and refugees, such as asylum centres, to ensure that antenatal care services have accurate and up-to-date information about a woman's current address during her pregnancy
  • Providing an interpreter (who should not be a member of the woman's family, her legal guardian or her partner) who can communicate with the woman in her preferred language
  • Offer flexibility in the number and length of antenatal appointments when interpreting services are used
  • Provide information in a variety of formats, settings and languages
  • Healthcare professionals should be given training on:
    • the specific health needs of women who are recent migrants, asylum seekers or refugees, such as needs arising from female genital mutilation or HIV
    • the specific social, religious and psychological needs of women in these groups.

Pregnant women aged under 20 years old

  • Working in partnership with local education authorities and voluntary agencies to improve access to, and continuing contact with, antenatal services for young women aged under 20.
  • Consider commissioning a specialist antenatal service for young women under the age of 20. This could include antenatal care and education in peer groups in different locations (e.g. schools, colleges, GP surgeries) or offering peer group support at the same time as antenatal appointments in a one-stop shop where a range of services can be accessed at the same time .
  • Offering a named midwife, who should take responsibility for and provide the majority of the woman's antenatal care, and provide a direct phone number for the midwife.
  • Training for healthcare professionals to ensure they are knowledgeable about safeguarding responsibilities for both the young woman and her unborn baby and the most recent government guidance on consent for examination or treatment
  • Be aware that the young woman may be dealing with other social problems and offer age-appropriate information in a variety of formats.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS

clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

About SCIE

The Social Care Institute for Excellence (SCIE) was launched in October 2001 as part of the Government's drive to improve social care. It is an independent registered charity, governed by a board of trustees. Its role is to promote and advance knowledge about good practice in social care across England, Wales and Northern Ireland.

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This page was last updated: 22 September 2010

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.