Quality standard

Quality statement 5: Women with no antenatal care

Quality statement

Pregnant women who present in labour with no antenatal care have an obstetric assessment and medical examination, and assessment of their medical, psychological, and social history.

Rationale

Women in labour with no antenatal care are at increased risk of serious obstetric and medical complications for themselves and their babies because there is no baseline information and no birth plan. Assessment of the woman's medical, psychological and social history, as far as possible, as well obstetric assessment and medical examination, is likely to establish the reason she has not accessed antenatal care. It also indicates the likelihood of complications during labour and birth and identifies the woman's preferences and needs. A complete assessment helps reduce the risk of adverse outcomes during labour and birth, recognise potential vulnerability and safeguarding concerns, and allows planning of further support, such as postnatal care and continuity of midwifery care.

Quality measures

Structure

a) Evidence of local processes to ensure that pregnant women who present in labour with no antenatal care have an obstetric assessment and medical examination by an obstetrician.

Data source: Local data collection, for example, written protocols, service specifications, and staff rotas.

b) Evidence of local processes to ensure that pregnant women who present in labour with no antenatal care have an assessment of their medical, psychological and social history.

Data source: Local data collection, for example, written protocols, service specifications, staff training records.

c) Evidence of training for healthcare professionals on understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.

Data source: Local data collection, for example, staff training records.

Process

a) Proportion of pregnant women who present in labour with no antenatal care who have an obstetric assessment and medical examination.

Numerator – the number in the denominator who had an obstetric assessment and medical examination.

Denominator – the number of pregnant women who present in labour with no antenatal care.

Data source: Local data collection, for example, audit of maternity records.

b) Proportion of pregnant women who present in labour with no antenatal care who have an assessment of their medical, psychological and social history.

Numerator – the number in the denominator who have an assessment of their medical, psychological and social history.

Denominator – the number of pregnant women who present in labour with no antenatal care.

Data source: Local data collection, for example, audit of maternity records.

Outcomes

a) Incidence of maternal mortality associated with no antenatal care on presentation in labour.

Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of women who died and had received no antenatal care.

b) Incidence of neonatal mortality associated with no antenatal care for the mother on presentation in labour.

Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of neonatal deaths for women who received no antenatal care.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that they have written protocols and service specifications in place so that pregnant women presenting in labour with no antenatal care have an obstetric assessment and medical examination by an obstetrician. They also ensure that staff are trained in understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.

Obstetricians lead an obstetric assessment and medical examination of pregnant women who present in labour with no antenatal care so that they can plan further testing and management. Midwives or obstetricians sensitively and respectfully assess the woman's medical, psychological and social history. This enables care for labour and birth to be planned, in line with the risk of adverse outcomes and the woman's preferences. Midwives and obstetricians also look for signs of potential vulnerability and safeguarding concerns, identify the need for further support, such as postnatal care, and offer referral to other services as needed.

Commissioners (clinical commissioning groups) ensure that they commission services that provide an obstetric assessment and medical examination by an obstetrician for pregnant women who present in labour with no antenatal care. They also ensure that services train staff in understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.

Pregnant women in labour who have not had care during pregnancy have a range of assessments, led by healthcare professionals specialising in childbirth, so that they can discuss their preferences and be supported to plan their care during labour and birth. Any potential concerns about the woman's welfare and her baby's can be identified and further support after birth planned.

Definitions of terms used in this quality statement

Obstetric assessment and medical examination

Assessments in line with those described in NICE's guideline on intrapartum care for healthy women and babies, section 1.4, and assessment of the unborn baby as described in NICE's guideline on intrapartum care for women with existing medical conditions and obstetric complications and their babies, recommendation 1.18.6. This includes listening to the woman's story and taking into account her preferences and her emotional and psychological needs when performing an initial assessment. [NICE's guideline on intrapartum care for healthy women and babies]

Assessment of medical, psychological and social history

This should be undertaken as fully as possible to establish the woman's life situation and, if possible, to find out why she has not accessed antenatal care. This, in combination with medical and obstetric assessments, indicates her risk of complications during labour and birth. She should also be asked who (if anyone) she would like to support her as her birth companion(s) during labour.

Potential vulnerability and safeguarding concerns should be sensitively explored.

[Adapted from NICE's guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies, recommendation 1.18.4 and evidence review R, and NICE's guideline on pregnancy and complex social factors]

Equality and diversity considerations

A woman's language needs should be established and women with difficulty understanding, speaking and reading English should have access to an interpreter, link worker or advocate. The interpreter, link worker or advocate should not be a member of the woman's family, her legal guardian or her partner, and they should communicate with the woman in her preferred language. This enables women who have difficulty speaking and reading English to give their own account of their situation.

Women with no antenatal care should also be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with healthcare professionals during assessments. Information should be accessible to women who do not speak or read English and it should be culturally appropriate.

For women with no antenatal care who have additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.