Using our recommendations: maternity and neonatal health

How to use NICE guidance to reduce health inequalities during and after pregnancy.

The challenge

Maternal and neonatal mortality rates have fallen over the past decade, but the gap between ethnic groups has grown:

Black women are 3 times more likely to die during or soon after pregnancy compared with White women
the maternal death rate for women from Asian ethnic backgrounds is 2 times higher than that of White women
babies from the Black ethnic group have the highest rates of stillbirths and baby deaths, with babies from the Asian ethnic group consistently the second highest.

There are many specific examples of health inequalities in maternity and neonatal care.

To show you how you can use our guidance and resources when addressing these in commissioning services etc, we will focus on routine antenatal appointments.

We will refer to this to provide examples of the support we can offer you.

Routine antenatal appointments

Our antenatal care guideline recommends supporting women and pregnant people to attend their first antenatal (‘booking’) appointment by 10 weeks of pregnancy.

This enables early identification of potential risks and makes sure care is planned according to the person’s needs. But statistics show large variation in attendance when broken down by ethnicity of the mother.

White women are consistently the most likely to attend booking by 10 weeks, and Black women are the least likely.

Booking and subsequent appointments are also key opportunities for ongoing risk assessments covering medical, genetic, social and emotional factors.

Although checks on previous obstetric history are common, assessments of mental health and social circumstances are far less consistent. Improving these areas can help reduce adverse outcomes for both parent and baby.

Guidance

Our maternity and neonatal guidance gives you a clear structure to help you deliver care that is as equitable and accessible as possible.

You can find specific guidance on our maternity services and infants and neonates topic pages.

However, it is also important for you to consider the wider influencing factors that contribute to health inequalities so may also want to consider reviewing guidance we have in other topic areas such as:

[Guidance] implementation strategies aim to help ensure that disparities in outcomes and experiences of mothers and their babies are reduced, and that maternity services can deliver the best possible care.

Marie Anne LedinghamConsultant clinical advisor at NICE, consultant obstetrician at NHS Greater Glasgow and Clyde

Equality and Health Inequalities: make your health and care decisions fair and inclusive

We consider health inequalities at every stage of guidance development.

This starts with an Equality and Health Inequalities Impact Assessment (EHIA). This helps ensure recommendations promote equity, address disparities and do not adversely affect any groups.

In the EHIA for antenatal care (PDF) there are sections on women from different socioeconomic groups and family backgrounds. These explain the inequality considerations and recommendations made by the appraisal committee in relation to antenatal appointments and ethnicity.

Implementing our recommendations: more tools and resources

Using our tailored tools and resources can help you implement our guidance and overcome barriers to uptake and adoption. This will also support you to reduce unneeded variation and health inequalities.

We have included below information and examples of the most common type of tools and resources.

However, there are many more bespoke resources you can access if needed. You can find all of these on the tools and resources tab of all guidance.

You can use our indicators in a number of different ways to address health inequalities, including:

identifying where improvements are needed
setting priorities for quality improvement and support
creating local performance dashboards
benchmarking performance against national data
supporting local quality improvement schemes
showing progress that local health systems are making on outcomes.

Our indicators include:

Pregnancy and neonates: 10-week booking appointments in pregnancy (IND62)

This covers the proportion of pregnant women accessing antenatal care who come for a booking appointment by 10 weeks and 0 days.

Pregnancy and neonates: smokers at booking appointments (IND18)

This covers the proportion of pregnant women who smoke at the time of their booking appointment.

Pregnancy and neonates: mental health at booking appointment (IND63)

This covers the proportion of pregnant women who were asked about their mental health at their booking appointment.

Find out more about how you can use our indicators and how we develop them.

You can use these to evaluate whether practice in your locality is in line with the recommendations in our guidance.

They can also help you plan future activity to meet recommendations relating to health inequalities. You will find them under the audit and service improvement heading.

The recommendations about antenatal appointments are included in the base line assessment tools for our antenatal care and pregnancy and complex social factors guidelines.

These tools can help you estimate the resource impact from implementing new guidance or a change to existing guidance.

By using them, you can identify where resources need to be allocated to improve access and outcomes, which will include those from underserved populations.

They will highlight both the financial and capacity implications and also any benefits to health outcomes arising from implementing the guidance. .

These can provide you with further information and support on challenging implementation issues and unwarranted variation that may be associated with the guidance.

There are many different types of these resources including:

educational resources
clinical and patient decision aids
summary documents
implementation toolkits
commissioning guides.

Examples of our resources include:

Our interactive schedule of antenatal appointments resource (PDF) details best practice for the routine antenatal appointments that should be offered during pregnancy.
This includes the scheduling and content of the appointments, and what questions to ask about mental health and social and personal circumstances.
You can use this resource to review what routine antenatal appointments should be scheduled and the content of each of these appointments. The resource also directs you to additional guidance and support.
Our interactive mental health checklist (PDF) provides you with specific information regarding the mental health assessment and any follow-up actions that may need to be taken. This should be used at both the first and subsequent antenatal appointments.
Our implementation support toolkit for antenatal care was developed in collaboration with system partners. It provides you with targeted support on how to try to reduce the unwarranted variation of routine antenatal appointments, ethnic health inequalities and smoking.

Real world case studies: how our resources made an impact

Hear from real people who delivered real outcomes by using NICE guidance and other tools.

Our case studies provide valuable insights into how you can use our guidance across various healthcare settings too.

They highlight:

innovative approaches
challenges faced
the impact of implementing evidence-based recommendations on patient outcomes and service delivery.

Our case studies relating to health inequalities and antenatal care include:

Understanding local themes for Black maternity service users booking late (over 16 weeks’ gestation)

Organisation: Frimley Health ICB; NHS Frimley Health Foundation Trust. Organisation type: NHS Trust; Local Maternity and Neonatal System.

Supporting pregnant people to stop smoking

Organisation: Manchester University NHS Foundation Trust – St Mary's Hospital, Wythenshawe Hospital. Organisation type: NHS Trust.