Shared learning database

Plymouth Community Healthcare (CiC)
Published date:
January 2014

Great Expectations antenatal education programme is a multidisciplinary parenting course for pregnant women, their partner (or chosen supporter). The development and delivery of this programme has brought together a range of practitioners, who have reviewed the evidence base, looked at NICE guidance, quality standards and examples of best practice. These have been considered alongside service user feedback and evaluations, to design an interactive, practical, and engaging parent education package.

The development of Great Expectations has been overseen by a quality assurance group, with representatives from a range of partners, who have maintained a focus on quality, equity, accessibility and managing capacity.

The implementation of this programme has enhanced the antenatal care pathway offering pregnant women (and partners) greater choice, and increased accessibility across a range of venues, times and days of the week.

This example was originally submitted to demonstrate implementation of NICE guidance CG62. This guidance has now been updated and replaced by CG192. The example has been reviewed and continues to align generally with the new guidance. The new guidance should be referred to if replicating any aspect of this example.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Aim: The aim of this project is to offer parents-to-be, a comprehensive antenatal education programme, which is engaging, practical and interactive in order to equip them with the knowledge and skills to make positive lifestyle choices for a healthy pregnancy, birth and healthy baby. Great Expectations aims to provide continuity, quality and accessibility to all pregnant women, their partner (or chosen supporter) across the City of Plymouth, offering greater choice throughout the antenatal care pathway.

The programme is broken down into 6 weekly sessions, which have key objectives relating to the chronology of a pregnancy and birth:

  • Week 1. Great Start: addresses the key public health messages for a healthy pregnancy (smoking/nutrition/emotional attachment/physical activity)
  • Week 2. Changes for me and us: addresses changing relationships, managing challenges, emotional/mental health, developing an emotional attachment with the foetus/baby, understanding baby's development and the impact of environmental factors/stimulation/stress and health.
  • Weeks 3 & 4. Addresses normal birth processes, stages of labour, birth interventions, coping strategies, being a birth partner, birth choices and possible interventions.
  • Week 5. Welcome to the world: addresses meeting baby for the first time, skin to skin contact, understanding early communication, responsive parenting, breastfeeding and bonding.
  • Week 6. Ten days and beyond: introduces the Healthy child programme, support networks, community resources, managing time, prioritising infant's needs, maintaining a safe environment and child health.

Please read about our objectives for the programme in the supporting material.

Reasons for implementing your project

Plymouth has a population of 259,000 (2012 health profile) the city is located on the south coast of Devon, with a strong maritime history. The health of people in Plymouth is generally worse than the England average. Deprivation is higher than average and about 10,400 children live in poverty. Life expectancy for both men and women is lower than the England average. About 18.8% of Year 6 children are classified as obese. Levels of teenage pregnancy, breast feeding initiation and smoking in pregnancy are worse than the England average.

There are significant health inequalities across the City, with many people experiencing poor health and a shortened life expectancy. The Public Health department in Plymouth is committed to addressing the health needs of the population through a life course approach. A local health needs assessment identified a lack of continuity in the provision of antenatal care across the City of Plymouth. There were discrepancies in the length, content, quality and accessibility to antenatal education. The assessment found examples of good practice, which had been developed in response to local need and implemented by enthusiastic practitioners. However there was a lack of coordination, monitoring, evaluation, and governance, underpinned by a robust evidence base and quality standards.

The Great Expectations quality assurance group was developed, to enable a multidisciplinary team to look at quality standards, best practice guidance, accessibility, capacity, resources, monitoring, evaluation, training needs, audit and research.

This partnership programme has provided an opportunity to explore the capacity of other organisations to contribute to a shared aim and improve the quality of antenatal care. Great Expectations has drawn on the expertise of a wide range of contributors, which has reduced the impact on any single service provider. It has therefore, proved to be cost effective and sustainable. The programme has embedded public health initiatives, such as the healthy start scheme, healthy weight during pregnancy, and healthy child programme, breastfeeding, and accident prevention, reduction in smoking and positive maternal/infant mental health. It addresses the public health outcomes framework and contributes to the many of the strategic aims of the city.

How did you implement the project

The Great Expectations quality assurance group gained support for the initiative at strategic level across all the partner organisations. A series of stakeholder events enabled practitioners to contribute to the programme development, sharing their concerns and experiences. Great expectation 'champions' were nominated (or volunteered) who were able to represent their teams and be advocates for their service.

This partnership approach enabled the programme to be designed around realistic timescales, with agreement between services about the roles, responsibilities, accountability, and commitment of each provider. A joint funding contribution from the public health department and the local authority secured a coordinators role, provided via a midwifery secondment. This pivotal role provides a point of contact, leadership, coordination, support, and planning. The same funding stream allocated a development budget which led to the production of training resources, parent resource packs; facilitator's manual, branding and marketing. This investment and provision of a quality product has been received positively by practitioners delivering the programme.

The programme was initially piloted in one children's centre, in a deprived area of Plymouth with close monitoring and evaluation. The programme has been developed through small scale implementation, evaluation and modification. The programme was then trialled in other areas across the City with different profiles and demographics to assess transferability and to evaluate whether it met the needs of all socio-economic groups.

The team then addressed training needs and a phased role out across the city in order to be flexible with the phasing out of older programmes. This ensured that health practitioners and children's centre staff felt confident about delivering the programme. The team offered an opportunity for shadowing experienced facilitators and mentorship. Great Expectations is now a universal antenatal intervention, offered across the city on a rolling programme.

For further detail on methods, please see the full submission in the supporting material.

Key findings

The programme has a robust system of evaluation. Each individual session is evaluated at the beginning and end, using a "confidence ladder". The complete programme is evaluated at the beginning and end using a "distance travelled tool". The evaluations are collated into a quarterly report by the children's centres, which then feed into the Great Expectations quality assurance group for oversight and monitoring. The programme has also received ethics approval for a University of Plymouth research project, involving 3rd year medical students in a 3-year longitudinal study. The research will focus on health outcomes and choices made, as well as specific behaviours, such as breastfeeding, continued engagement with the children's centre and uptake of healthy start vitamins.
For detailed results, please see the full submission in the supporting material.

Key learning points

We have endeavoured to involve our partner organisations throughout the development, and implementation of this programme. This has fostered ownership of the content and added value through a multidisciplinary team contribution. The early involvement of stakeholder was crucial to gaining support, identifying shared aims, analysing data, local needs assessment, and bringing together a quality assurance group.

By identifying Great Expectation champions, the programme has benefitted from motivated and enthusiastic individuals who are keen to promote the programme within their service. However, this partnership approach has also proved a challenge at times, in agreeing timescales, outcomes and session content. The coordinators role has been crucial in addressing these challenges, negotiating compromise and project managing its implementation.

Great Expectations has attracted attention locally, with our neighbouring counties, with calls to present our initiative across the Southwest peninsular. We are currently supporting another county to implement Great expectations. We anticipate submitting the University of Plymouth research finding for peer review and publication. Locally we intend to produce an annual report which will incorporate the city-wide evaluations.

Contact details

Jan Potter
Public Health improvement manager
Plymouth Community Healthcare (CiC)

Primary care
Is the example industry-sponsored in any way?