House of Commons - Health

Select Committee on Health Eighth Report

2. Disadvantaged groups and access to maternity services: the current situation

What evidence is there that disadvantaged groups do not have full access to maternity services?

What evidence is available and what are the gaps in knowledge?

8. All of those who contributed to our inquiry attested to the existence of inequalities in access to maternity services. The Royal College of Obstetricians and Gynaecologists (RCOG) told us that:

Maternity care is available to all women in the UK but there is no doubt that there are inequalities in access to care: some women do not take advantage of the services provided and others find it difficult to access the care or do not find that the services meet their needs.[2]

9. Jenny McLeish, Social Policy Officer at the Maternity Alliance indicated two ways in which women encountered inequalities in access to maternity services:

One is actually in getting through the door, whether that is through physical access or through knowing about the services; and the second thing is the inequality of access to a good service when they are actually with the carer, whether they get a proper service, whether they get a decent and humane, kind service.[3]

10. Diane Jones, a consultant midwife at Newham Healthcare NHS Trust, also argued that disadvantaged groups encountered inequalities in access to care owing to a lack of awareness about available services. She told us that women who were "more aware … and … more assertive and know how to access health care are able to do so far better than others."[4] Lesley Spires, Head Midwife for One to One and community midwifery services and Birth Centre Manager from Queen Charlotte's and Chelsea Hospital agreed that "it is one thing to provide the service but it is another thing for that woman to know that the service is there."[5]

11. While these statements reinforced the conviction with which we undertook this inquiry — that some women did encounter barriers in terms of contact with maternity services and in terms of gaining access to appropriate care and support — we also heard that both qualitative and quantitative evidence on inequalities in access to care was limited. The National Perinatal Epidemiology Unit (NPEU) asserted that "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."[6]

12. The Department of Midwifery at City University, London drew to our attention its research on maternal and perinatal health statistics which attempted to determine the extent to which access to health care could be measured for specific groups in the population. In outlining this work, the Department of Midwifery assessed the state of current resources for analysing inequalities in access to care:

Data and statistics that are routinely available for maternal and perinatal health care in England are inadequate for measuring the level of access to maternity and neonatal services for groups within the population including minority ethnic groups and socially disadvantaged groups. Lack of complete and valid recording of ethnic group is compounded by the absence of reliable socio-economic data on mothers and their babies, making any comparisons of inequalities in health outcomes along with any assessment of equity of access for vulnerable groups, impossible.[7]

13. Given the burden of data collection currently imposed on midwives we are concerned that this process should not become any more time-consuming. However, when we examined the collection of maternity care data as part of our first inquiry, we heard evidence that maternity service planners and providers were impeded in their work by lack of data on the socio-economic and ethnic status of pregnant women, and on relevant pregnancy and child health outcomes.

14. We recommend that detailed socio-economic and ethnic data should be recorded in a standardised way in all national datasets and that analyses of these data should be routinely published as well as being made available to researchers for more detailed analyses.

15. Several of our witnesses suggested that one important gap in knowledge about inequalities in access to maternity care has been created by the lack of information on women who give birth to their babies without having booked any maternity care at all. Carolyn Roth, a member of the management committee of Women's Health and Family Services, and a researcher at City University, London, told us that she had been involved in a small survey which attempted to collate figures on the number of women who arrived at hospital in labour without having received any kind of antenatal care. Of the 33 units surveyed, nine were able to respond and it was found that about 4% of women had received no antenatal care whatsoever.[8] Overall, in reporting that very few maternity units could produce the relevant figures, Carolyn Roth told us that this was symptomatic of a wider problem:

It is a theme that runs through a lot of the issues regarding access to services which is what is not encountered does not count. In other words, if you cannot actually enumerate what the dimensions of the problem are it is actually very difficult to identify shortcomings in the service.[9]

16. Systematic reviews by the NPEU found "surprisingly little recent evidence about patterns of attendance at antenatal care for different social groups."[10] The exception to this was a study undertaken in the mid-1990s which suggested that on average, women from South Asian backgrounds started maternity care later and made fewer visits than white women. The NPEU also found evidence that South Asian women might be up to 70% less likely to receive prenatal testing for haemoglobin disorders and Down's Syndrome. Some of the work in this area suggested that South Asian women might be less likely to be offered testing.[11]

17. According to the NPEU, information about social and ethnic differences in access to postnatal and infant care was even more limited although evaluations of initiatives such as Sure Start[12] and the Teenage Pregnancy Strategy might enhance the evidence base, as the NPEU explained:

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.[13]

18. We asked our witnesses whether there was any correlation between poor access to care and areas of general social deprivation. We heard that access often depended on the work of particular projects, and of particular individuals in improving access for disadvantaged groups. Christine Gowdridge from Maternity Alliance told us that:

this kind of accidental way in which particular midwives come along and create specialist services shows that provision is extremely haphazard … I do not think that it is based on geography as such although there are obviously issues around rural areas, but it is more based on chance.[14]

19. A great many of the examples of specific projects to improve access which were drawn to our attention during this inquiry, were based in areas with large communities of women from disadvantaged groups. We recognise, however, that the needs of disadvantaged women living in areas without such identifiable communities, might not be identified. Christine Gowdridge, Director of Maternity Alliance, told us that access "is much more of a problem for an asylum seeker in an area which is not identified as an area of deprivation than it would be for one living in North London which is."[15] Even if services were accessed, according to the Centre for Nursing and Midwifery Research, in such areas "midwives were deskilled and individual clients often received a poorer service."[16]

20. Jo Garcia, from the NPEU, pointed to a lack of evidence on possible links between poor access to care and general deprivation in a particular geographical area. She told us that little work had been done that examined services "in terms of … the level of staffing or spending or comparing places in terms of women's views of care." Ms Garcia went on to say that it was "not always easy" to ascertain whether differences in access to care were related to resources, or to the "attitudes and structures" inherent in a particular area or service, but she told us that she was unaware of any research which compared spending on maternity services in the poorest areas with that in the more affluent areas.[17]

21. It may be that maternity services are less inequitable than other health services because of the regular pattern of antenatal and postnatal visits that midwives conduct. However inequalities remain a serious issue, particularly given the impact that a positive experience of appropriate care can make in this critical period of individual and family life, and the powerfully negative effect that inequalities can have on every aspect of life.

22. If maternity services are to meet the needs of disadvantaged women, babies and families, the evidence base on which policy decisions and service developments are made must be expanded. We recommend that the Department commission programmes of quantitative and qualitative research so that an accurate assessment of the extent to which women who do not gain full access to maternity care can be made, the reasons for inequalities and inequities established and further action taken to address these inequalities.

What can be learned from the Confidential Enquiries into Maternal Deaths?

23. While maternal deaths are now very rare, policy makers and services providers draw on the investigation of these cases when considering those factors which may contribute to adverse pregnancy outcomes other than death. In 1952 the Department (then the Ministry of Health) established the Confidential Enquiry into Maternal Deaths in the United Kingdom (CEMD). Since then the Enquiry, a centrally-directed self-audit for health professionals involved in maternity services, has been undertaken at intervals, and its findings incorporated into Government health policy and obstetric practice.[18]

24. The latest report, Why Mothers Die 1997-99: The Confidential Enquiries into Maternal Deaths, as well as finding that the maternal death rate amongst women in the group where neither the woman nor her partner had a stated occupation was 20 times higher than that for women in the highest two social classes, extended the scope of the investigation to include consideration of the wider aspects of health and health inequalities in relation to maternal deaths.

25. Why Mothers Die indicated that for women from some minority ethnic groups the risk of maternal death was twice that for white women. Of the cases of maternal death investigated by CEMD, more than 25% of women from minority ethnic communities either first made contact with the maternity services when they were more than five months pregnant or missed four or more routine appointments. A large number of the women from ethnic minority groups spoke little English and in many cases, family members acted as interpreters. Why Mothers Die reported on several cases where children were used to interpret intimate personal or social details of the mother, and vital information was not communicated.[19]

26. CEMD also found that a disproportionate number of women from the travelling community were likely to die. By evaluating a range of factors that may have played a part in cases of maternal death Why Mothers Die illustrated not only the relationship between social exclusion and poor pregnancy outcomes, but also that late, sporadic or inadequate care was another common factor.

27. Jenny McLeish, Social Policy Officer at Maternity Alliance, told us that the links made in Why Mothers Die between poor access to care and maternal death represented:

the most extreme end … the tip of the iceberg where the mother actually dies as a result of lack of access to care. Working backwards from that, I think you can hypothesize fairly confidently that there will be other poorer outcomes going on that are harder to pick up in the pattern but … less drastic consequences for the same problem.[20]

What is the Government doing to help disadvantaged women gain access to maternity services?

What is the role of maternity services in the context of the Government's Health Inequalities Strategy?

28. In 1997 the Government commissioned the Independent Inquiry into Inequalities in Health, chaired by Sir Donald Acheson. The Inquiry listed support for mothers with very young children as one of three top priorities. It also emphasised the importance of making early interventions to improve health and of a focus on the health of mothers and young children in addressing infant mortality. The Inquiry pointed to the need to break the "intergenerational cycle" of health inequalities and identified this as a long term aim.[21]

29. The NHS Plan, published in July 2000, made health inequalities a priority in order to tackle the 'inverse care law', which suggests that those in greatest need are least likely to receive the health services that they require.[22] The Department outlined the implications of the Plan for maternity services:

this means knowing where pregnant women are and how they want and need their care delivered and configured. It means understanding the local patterns of disadvantage and exclusion; and designing services that reach out to ensure those most in need have prompt access to the support they need.[23]

30. The NHS Plan described the health of mother and baby at the very beginning of the baby's life as being the foundation for health throughout life but noted the wide variation in infant mortality rates across the country and in terms of social class and ethnic origin. Babies born to fathers in unskilled or semi-skilled occupations have a mortality rate 1.6 times higher than those in professional or managerial occupations and children of women born in Pakistan are twice as likely to die in their first year than children of women born in the UK.[24]

31. The NHS Plan set targets for reducing smoking in pregnancy as it can be associated with poor birth outcomes. With the help of specialist smoking cessation services as part of antenatal care, the Government aimed to reduce by 55,000 the total number of women who smoke in pregnancy by 2010.[25] The Plan also stated that while mental health services were not always sensitive to the needs of women, women were more likely to suffer from mental health problems (particularly anxiety, depression and eating disorders) and that 10-15% of women experience postnatal depression after childbirth. As a means of focusing on the mental health needs of women, the Government directed that services should be redesigned to ensure the availability of women-only day centres across the country.[26]

32. In August 2001 the Government published Tackling Health Inequalities—Consultation on a Plan for Delivery. One of the six priority themes in the consultation document was the need to produce a sure foundation for health through healthy pregnancy and early childhood. The Results of the Consultation Exercise, published in July 2002, listed suggestions for action on the theme:

Developing more targeted support for maternal health and the health of developing babies, with specific emphasis on maternal nutrition before, during and after pregnancy

Reducing the incidence of low birth weight babies by tackling smoking and poor diet

Promoting and supporting breastfeeding

Developing parenting skills through family support services and life skills programmes

Improving access to maternity services, including antenatal classes for disadvantaged groups, those with physical disabilities, learning disabilities, and non-English speaking women

Increasing professional support for identifying and tackling postnatal depression, a key indicator of maternal health, and improving training on domestic violence.

33. The consultation also revealed that professional and lay support in communities was seen as crucial to providing proper support in pregnancy and early childhood, but that a great many respondents had concerns about resources, capacity and training and development.[27]

34. This consultation was used to inform the Government's cross-cutting spending review on health inequalities which took place over summer 2002. Among the priority interventions likely to make a major impact on the infant mortality target and on early years development, the review identified reducing smoking in pregnancy, increasing breastfeeding rates, improving diet and enhancing support for families. As part of the review, targets set by The NHS Plan on increasing life expectancy (by geographical area) and infant mortality (by social class) were combined into a single Public Service Agreement (PSA) by 2010 to reduce inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth. This target has also been incorporated in the National PSA for Local Government.[28]

35. The Priorities and Planning Framework for the NHS, 2003-2006, published in October 2002, afforded health inequalities a high profile and set targets to support progress towards the main PSA aim, including two targets which had direct relevance to maternity services:

to deliver a one percentage point reduction per year in the proportion of women continuing to smoke throughout pregnancy, focusing especially on smokers from disadvantaged groups [the Department reported that smoking throughout pregnancy decreased from 23% in 1995 to 19% in 2000 in England]
to deliver an increase of two percentage points per year in breastfeeding initiation rate, focusing especially on women from disadvantaged groups [the Department reported that breast feeding initiation increased from 68% in 1995 to 71% in 2000 in England and Wales].[29]

The main findings of the health inequalities consultation and of the spending review have been used in the Department's ongoing work in leading on the development of an All-Government Delivery Plan on health inequalities.[30]

36. However, the RCOG made clear to us its disappointment that in light of the findings and recommendations of CEMD, the targets set for Strategic Health Authorities and PCTs in the Priorities and Planning Framework 2003-2006 "included so little" that was relevant to "improving maternity care and outcomes":

The College is concerned that this may delay, through lack of resources, any positive planning for change in service provision.[31]

37. A great many of those service providers who contributed to our inquiry described their involvement with Government programmes such as Health Action Zones, Neighbourhood Renewal Funds and Sure Start. Diane Jones, a consultant midwife from Newham Healthcare, told us that the community focus of Sure Start complemented caseload midwifery schemes:

Part of our strategy comes through from working with the community groups, bringing them together on what the priorities are for the community rather than health care professionals deciding what is necessary for the community.[32]

38. However, we heard that maternity services encountered problems in tapping the resources offered by such initiatives:

You need to find out who the key people are who make the decisions about the funding and that can be very, very difficult … the balance tends to shift, one moment it sits in social services, then it is with education or the PCT. You have to have an awareness of these issues.

In the majority of cases you are not informed that there are these things going on, you have to go out and find it and if you are not clued up as to where to go that can be very difficult. Once we have got in there it has been great. It is just about finding the right places to go.[33]

39. Another problem drawn to our attention was the short-term nature of the funding allocated to projects. While such funding afforded services an opportunity to undertake innovative work, Lesley Spires from Queen Charlotte's and Chelsea Hospital told us that it was difficult to recruit staff for short-term programmes, "even if some of them go on for four years."[34] As Carolyn Roth, from Women's Health and Family Services told us:

There is a constant insecurity about not only sustaining the work but also the continuity of employment for the people who are working on the project.[35]

40. We recommend that the Department provide PCTs and acute trusts with relevant and timely information to enable maternity care teams to use the opportunities and resources offered by the Government through projects and initiatives such as Sure Start, to recruit more staff and provide specialised services for disadvantaged women and their families. We further recommend that the Department should ensure that best practice be shared in relation to these centrally-funded projects. We further recommend that the Department should ensure that best practice be shared in relation to sustaining the work of a project after the allocated funds have been used.

How will the Children's National Service Framework address inequalities in access to maternity

services?

41. The Development of a National Service Framework (NSF) for Children was announced in February 2001. According to the Department:

In the new architecture of the NHS the setting of national standards through the NSF will be the most effective way of ensuring consistency of service provision to all groups of women, including those who use the current services least, and quality in a devolved health care system; whilst at the same time continuing to allow local health systems to develop a 'best fit' … the maternity module will develop national standards of care to cover the provision of antenatal, intrapartum and postnatal services; and will look at how to make maternity services more flexible, accessible and appropriate for all, including the socially disadvantaged.[36]

42. The maternity module of the NSF is being developed by the Maternity External Working Group (EWG) and a sub-group has been appointed to work on inequalities and access. In an interim report issued in April 2003, the EWG made a number of recommendations on access to maternity care:

From pre-conception to post-birth all women need to have appropriate access to community, hospital and/or specialist services, including women with:
Healthy and uncomplicated pregnancies
Complicated pregnancies due to medical, psychological or social reasons; and
Ethnicity, poverty or social exclusion issues—e.g. prisoners, women with enduring mental health problems, women with disabilities, and women from transient populations
This can be helped by: setting standards of care to reduce health inequalities; recognising cultural diversity and providing appropriate communication and support; and by providing flexible services, for instance considering innovative approaches for women who have difficulty accessing services.[37]

43. The Department told us that the sub-group had identified two key questions in relation to inequalities in access to maternity services: how do services find hard-to-reach women; and how do services respond when these women do attend? The Department told us that in addressing these questions the sub-group would look at examples of good practice at local level, and at 'care pathways' that describe the journey of pregnant women through maternity services. The aim would be "to provide individual and personal care for each woman, without making assumptions about her needs from her appearance, her ability to communicate or her past history."[38]

44. The interim report on the development of the NSF has generally been received with enthusiasm. Jo Garcia, from the NPEU, welcomed the promotion of care pathways in the NSF. These, she told us, would:

help midwives to think about the sort of additional needs women might have and, even beyond that, help the service to think about how it might reach women … help make care more individualised without putting rules on by saying exactly what sort of care should be provided.[39]

45. The RCOG endorsed the recognition in Emerging Findings that providing appropriate services for women from disadvantaged groups would involve development of the skills of the maternity care workforce, and of lines of communication between health care and social care professionals, and between services and the women who use them. However, in the context of the shortages of maternity care staff which were drawn to our attention during our first inquiry, the RCOG told us that it was concerned that "effective implementation and change will only be possible with appropriate and additional training and education for health and social care professionals" and that this had resource and staffing implications.[40]

46. We welcome the interim findings of the Maternity External Working Group, and look forward to seeing the work of the sub-group appointed to examine inequalities and access. The difference for women and families will depend on the identification of effective strategies and the Government ensuring that the implementation of these strategies is achieved.

2 Ev 56 Back

3 Q 17 Back

4 Q 93 Back

5 Q 94 Back

6 Ev 3 Back

7 Ev 71 Back

8 Q 153 Back

9 Q 96 Back

10 Ev 3 Back

11 Ibid. Back

12 http://www.dfes.gov.uk/surestart/ Back

13 Ev 3 Back