Antenatal Education Service Development

As part of the 0 - 19 healthy child service redesign Public Health Suffolk (in their capacity as commissioner of the service) proposed the delivery of a universal antenatal education offer but without specification as to how this service would be delivered.

The Suffolk County Council Children and Young People’s Health Visiting Service were appointed to deliver this service through a competitive tendering exercise and on the successful award of the contract sought to further develop the service specification for antenatal education. The first stage included a mapping exercise to determine what services were currently delivered across the county, by which service providers and the location that services were delivered. This exercise identified a wide range of services being provided across the county by a variety of service providers without any standardised or evidence-based model being adopted.

The CYP service were unable to identify any specific NICE guidance or Quality Standard for the provision of antenatal education and subsequently made an approach to the local NICE Implementation and Core Local Authority GuidancE Review (NICER) group for support with this piece of work to ensure that an evidenced based model of service could be developed and delivered across the county.

During the initial stages of this project relevant NICE guidance and Quality Standards on antenatal healthcare were reviewed and this included:

• Antenatal care for uncomplicated pregnancies (CG62)
• Antenatal and postnatal mental health: clinical management and service guidance (CG192)
• Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors (CG110)
• Antenatal Care: Quality Standard (QS22)
• Antenatal and Postnatal Mental Health (QS115)

The guidance and quality standards were considered relevant as antenatal education is key a component of antenatal healthcare. The NICER Chair offered the support of Public Health Suffolk to undertake an evidence review and provide recommendations for service development in the absence of specific NICE guidance in this area.

Initial baseline assessment of the current and historic service provision identified that the universal offer of antenatal education was inconsistent across the county for mothers, partners and families.

There were numerous course and groups in existence, however there was no assurance that the services offered were evidence based and the content appeared to reflect local demands rather than a comprehensive assessment of need.

It was further identified that no evaluation of outcomes for either mother, partners or children were embedded into any of the service models being delivered. Therefore, cost effectiveness of the antenatal education offer, could not be evidenced by any of the existing service providers. A further issue was that due to the universal nature of the offer and limited to service user data, there was no way of identifying specific groups at risk of disadvantage or pregnancies with complex social factors. This meant that opportunities to offer a patient centred approach designed to reduce health inequalities were being missed.

The evidence review commissioned through Public Health Suffolk sought to consider the evidence base for antenatal education and make recommendations for options for service delivery which might improve efficiencies and help to reduce health inequalities.

Suffolk has a population of 758,00 people across a geographical area of almost 3800km2 There are 64 GP practices across the county, and three acute hospital Trusts commissioned to deliver NHS services by three CCGs, Ipswich and East Suffolk CCG, West Suffolk CCG and Lowestoft and Waveney CCG. There are around 7000 new births per annum in Suffolk, and the general fertility rate in the county at 62.1 per 1000 women aged 15-44 is similar to the rate in England (61.2 per 1000),

In general pregnancy related outcomes are similar in Suffolk to the England, except for the caesarean section rate which is 3.3% lower. However, health outcomes for babies and children in respect of hospital admissions are worse in Suffolk with 90.4 per 1000 babies aged under 14 days admitted to hospital in Suffolk compared to 71 per 1000 in England. Similarly, the rate of emergency admissions for 0-4-year olds is 169.8 per 1000 population in Suffolk while in England the rate is only 157.6 per 1000 population. There are therefore opportunities within antenatal education to support parents in improving health outcomes for infants and reducing secondary healthcare usage.

The main challenge that was faced was the absence of specific NICE guidance or an established antenatal education quality standard to support service developments. The NICE Implementation and Core Local Authority GuidancE Review (NICER) group is established within Suffolk County Council to review published NICE Public Health guidance and facilitate and monitor the implementation of NICE guidance relevant to Suffolk County Council.

The need to develop an evidence-based model of service was discussed and agreed at the local NICER group and relevant NICE guidance and Quality Standards related to antenatal healthcare which would inform this project were identified. PHS were commissioned to undertake an independent evidence review using the existing DHSC guidance as starting point.

Relevant NICE guidance was considered to ensure that we took a holistic approach and considered antenatal education in the context of its role as a component of antenatal healthcare. Meetings between PHS and the CYP 0-19 service took place to develop the scope of the project based on the requirements within the service specification.

This allowed us to establish inclusion and exclusion criteria for the review and to consider the most recent guidance which had been published by the (then) Department of Health in 2011. In addition to considering the evidence base for interventions, the review sought to identify any economic evidence and to explore existing models of service delivery, for example the online provision developed by West Sussex.

Patient views on antenatal education were also considered using the results of the National Perinatal Maternity Audit from 2018 and the local Maternity Voices survey. To consider alternative methods of service delivery such as online / digital provision a teleconference was set up with a team led by the Consultant Midwife in Public Health at West Sussex County Council. This was instrumental in helping us to understand both the benefits and challenges associated with developing an online educational service and methods of evaluation for this type of model.

As a result, we have developed a new pathway for service delivery and launched an online education offer with an existing partner organisation.

The project was able to meet the initial aims and objectives which was to use a systematic review of the evidence for antenatal education and the views of parents to develop service provision.

The main result was to allow the service to develop a new pathway which included the introduction of an online resource for antenatal education in collaboration with a partner organisation. As this was a new service specification for the team in question it was not possible to quantify cost savings or increases in efficiency however the report highlighted economic analyses of antenatal education and made recommendations for outcomes to be measured to demonstrate effectiveness.

By reviewing recent evidence, the project was able to identify the most robust evidence for interventions as well as highlighting the interventions which should not be included in antenatal education as per the relevant antenatal NICE guidance.

Some of the key learning from this project and the approach that was taken include: Making use of the existing guidance which clarified the interface between antenatal healthcare and antenatal education.

In the absence of specific NICE guidance value can still be obtained from other NICE guidance relevant to the topic. For example, CG 192 identified that there was no robust evidence to include interventions designed to address perinatal or postnatal mental health within antenatal education. The value of undertaking a systematic literature review to helped inform decision making and allowed an up to date analysis of the evidence for antenatal education since the publication of DH guidance in 2011.

The independence of the review helps to reduce the risk of bias and enabled the service provider us to consider needs versus demand. This was the first type of partnership working with public health and it has been of significant benefit in helping the service to consider provision from different perspectives.

There has been a shared experience of learning both within the service and with external stakeholders. We have explored how best to use digital technology and discussed this with other organisations which has helped our understanding of the benefits and challenges. This has increased our confidence in considering new and innovative models for service delivery. We have adopted an online model which allows us to monitor uptake and to build in evaluation using a suitable outcome framework.