Memorandum by the National Perinatal Epidemiology
Unit (MA 11)
INEQUALITIES IN
ACCESS TO
MATERNITY SERVICES
The basis for this submission is a project on
inequalities in maternity care carried out jointly by the National
Perinatal Epidemiology Unit and Maternity Alliance and funded
by the Community Fund. The project has just finished and detailed
reports are available from the NPEU website (www.npeu.ox.ac.uk)
or from NPEU staff.
One part of the project was a systematic review
of evidence about inequalities in access to maternity care. It
looked for research about maternity and newborn care for families
in poverty, or in lower social groups or from minority ethnic
groups. It did not look systematically for research about all
the categories of people listed in the Committee's terms of reference,
though some evidence about care for these categories was reviewed
in another part of the work (a study of projects around England
aimed at very disadvantaged women) and further material is being
gathered for the Maternity sub-group of the Children's NSF. In
addition, Maternity Alliance has recently reported on the special
needs of groups like refugee and asylum-seeking women.
The research started from the position that
poorer people in UK had higher stillbirth and infant death rates
and more ill health, but that the reason for this was not clear.
Part of the reason may be that maternity care is worse for poorer
people, but there are other probable reasons to do with other
effects of poverty and things like smoking and breastfeeding differences.
Assumptions about differences in, say, the use of antenatal care
have been common among policy makers and have not been looked
at critically.
Without good evidence about who the maternity
services fail to reach and whether some categories of women and
babies get poorer care, we are not in a position to make sensible
changes to services. At a local level, audits are needed like
that done at King's to look at women who were recorded as delivering
without having booked for care. This showed that, in addition
to those who were genuinely unknown to the service, a proportion
of the women in the study had received care in pregnancy at the
hospital but had not been formally "booked". This suggests
that solutions there may need to include better record keeping
as well as outreach.
We found surprisingly little recent evidence
about patterns of attendance at antenatal care for different social
groups. The exception to this was a study done in the mid-1990s
that suggested that on average women from South Asian backgrounds
started care later and had fewer visits than White women. There
were no recent studies that described antenatal care for women
from different social class categories. We also found evidence
that women of South Asian origin might be up to 70% less likely
to receive prenatal testing for haemoglobin disorders and Down's
syndrome. A small number of the studies in this review distinguished
between the offer of screening and its uptake and these suggested
that South Asian women might also be less likely to be offered
testing. National and local responses are needed to address these
gaps in provision.
The findings from the Confidential Enquiries
in Maternal Deaths make it clear that some of the women who die
are not receiving appropriate antenatal care, but the response
to this needs to be based on better evidence about who misses
out on care and at what point. Any study of inequalities in antenatal
care and screening needs to look at women's pathways to care:
do some women delay their approach to a midwife or GP at the beginning
of pregnancy? Are there referral problems? Are some women unable
to get to the hospital for specialist care because of the practical
difficulties or cost of transport? Do all women get accessible
information about screening and opportunities to ask questions?
Are there specific groups with particular problems in accessing
care? At present we do not have answers to any of these questions.
Once we know more about the gaps, and about women's experiences
of accessing antenatal services, we can test out different solutions.
For example, we do not know if the provision of interpreting services
improves the appropriate and desired use of screening services
for non-English speaking women.
Information about social and ethnic differences
in access to postnatal and well-baby care was even more limited.
Some of these gaps in our knowledge may be filled by reports from
the evaluations of major initiatives like Sure Start and the Teenage
Pregnancy Strategy. For example, comparison of Sure Start areas
with control areas may help to understand whether and how midwives
and health visitors target their care to those in most need and
what difference it makes. The evaluations of both these initiatives
are in progress.
In addition to the reviews in this project about
access to maternity care we also carried out a review of the evidence
about interventions intended to benefit low-income and disadvantaged
mothers and babies. This is available on the NPEU website and
a summary can be done for the Committee if that would be useful.
The analysis of an interview study of low-income pregnant women
and new mothers is just being completed at NPEU.
May 2003
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