House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum by The National Childbirth Trust (MA10)

The Sub-committee will examine inequalities in access to care for pregnant women and for parents and babies from disadvantaged groups. The Sub-committee will consider the provision of appropriate care and advocacy services for:

— those from minority ethnic groups;

— refugees and asylum seekers;

— those who do not speak English as their first language;

— those who live in poverty;

— those who are homeless;

— those who live under threat of domestic violence;

— travellers;

— those with severe mental health problems;

— those with severe learning disabilities;

— those with severe physical disabilities.

1. INTRODUCTION

The National Childbirth Trust (NCT) is the leading UK-wide charity offering information and support in pregnancy, childbirth and early parenthood. Every year the NCT is in contact with 600,000 parents and parents-to-be, through our helplines, interactive website, support networks, antenatal classes, and local and national events. We have 48,000 members, 330 branches, and 1,500 trained workers including antenatal teachers, breastfeeding counsellors and postnatal leaders. We campaign for improvements to maternity services and care in the four countries of the UK. The NCT aims for all parents to have an experience of pregnancy, birth and early parenthood which enriches their lives and gives them confidence in being a parent.

This response will look at recommendations for the Committee on some of the above areas, plus issues affecting young mothers and fathers. We would ask the Committee to address their issues in this Inquiry as this group is often disadvantaged in terms of care, services and outcomes.

2. SOCIO-ECONOMIC DISADVANTAGE—GENERAL POINTS

The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) and Confidential Enquiry into Maternal Deaths (CEMD) reports show that women and their babies from socio-economically disadvantaged groups in society are more likely to die around the time of birth and babies are more likely to be born at a low-birth weight with all the attendant problems this causes. Women from disadvantaged groups are also less likely to breastfeed, lessening the chance of their baby having good health as an infant, a child and into adulthood. It also reduces her protection against some forms of cancer. Disadvantaged women are less likely to access healthcare early in their pregnancy and may find that accessing appropriate information and support is more difficult.

For disadvantaged women, be it through age, ethnicity, economic or domestic situation, or physical and mental disability, additional support during pregnancy and early parenthood can have an important and beneficial impact on her and her baby. An American study of mothers who had home visits in pregnancy and in their child's first two years were less likely to have been identified as perpetrators of child abuse. Among those who were socio-economically disadvantaged those who had received home visits had fewer subsequent births, increased birth interval, less time on income support and fewer behavioural problems associated with alcohol and other drugs, and fewer arrests[21]. Other research shows that one-to-one support during pregnancy can improve physical and mental health by assisting disadvantaged women to cope with their difficult circumstances. Supported women are less likely to feel unhappy during pregnancy and six weeks after birth they are more likely to be still breastfeeding, less likely to have introduced solid food too early, less likely to be feeling physically unwell, and their babies are less likely to have had worrying health problems. [22]A follow-up study found that the improvements in physical and emotional health of the children were still present seven years later. [23]

An independent evaluation of the Albany Practice, a midwifery practice in a deprived area of South East London found that its clients benefited from the different approach to midwifery in which they get to know their midwife and received greater continuity of care that could be offered by many other NHS Trusts. There were lower caesarean and instrumental delivery rates, higher home birth rates and higher breastfeeding rates, all of which benefit mothers and babies. The evaluation found that adopting similar models in other disadvantaged inner city areas could be beneficial for the health both of mothers and their children. [24]

Young women, and those from socio-economically disadvantaged backgrounds are less likely to breastfeed, and as a consequence, they and their children are more likely to suffer from poor health. Breastfeeding rates in England are amongst the lowest in Europe, with only 28% of babies receiving any breastmilk at four months of age. Women who left school at age 18 are twice as likely to still be breastfeeding at four months than those women who left at 16 years of age. [25]Yet breastfeeding is one of the simplest and most effective ways of improving the health of our children. Currently the decision to breastfeed is related to age, social class and mother's education so that children who are most at risk of poor health (due to poor housing, overcrowding, parental smoking and other social factors) are least likely to be breastfed. Formula fed babies are five times more likely to be admitted to hospital with gastro-enteritis in their first year[26], twice as likely to develop atopic eczema, wheezing[27] and ear infections[28] and five times more likely to have a urinary tract infection[29] than babies who are breastfed for at least four months. [30]For premature babies, there is no doubt that human milk reduces the risk of the life-threatening bowel disease, necrotising enterocolitis, and therefore saves lives as well as reducing hospital costs. [31]

As health of disadvantaged mothers and babies can be improved significantly through increased breastfeeding, there is a need to review patterns of visiting and how community midwives' time is spent to see if more effective support could be provided. Many women report that support available to them suddenly vanishes at the end of their care from a midwife, usually at 10 days after the birth. A better way of making the transition to health visitor care is needed, possibly at a later time[32] with more integration, more overt support for breastfeeding from health visitors (many of whom may need further training in this regard) and more emotional support for women themselves. However, more research is needed into the outcomes of different types of visiting and the way in which they benefit different groups[33]. Some women, particularly young women and those from different ethnic backgrounds may find peer support helpful from women who have the same background or speak the same language as they do. There are many areas of best practice and the Department of Health should fund more schemes that give women support in feeding at this crucial time.

Recommendations:

— Services should be developed continuously to improve the quality of care and support available. Resources should be targeted to ensure that women and families who are disadvantaged, likely to have access problems, or are known to have particular clinical needs, have the highest quality services available. For example, women appreciate having care from people whom they can get to know and with whom they can build up a relationship of trust and understanding.

— As disadvantaged women often have multiple needs (eg social support, housing advice, midwifery care and support, medical problems, obstetric complications) it is particularly important that there is a well coordinated multi-disciplinary team approach to providing care and that each women has one "key worker" or lead professional who coordinates her maternity care and whom she can go to at any stage.

— If working arrangements prevent all women in the NHS trust having care from midwives carrying their own caseload or working in a small team so that they can get to know women personally, then this kind of scheme should be implemented in the geographical areas with highest deprivation scores, or for particular client groups such as women with a history of psychiatric illness.

— Caseload midwifery ensures that the women and the midwife really get to know one another during pregnancy. If this model were adopted in other inner city areas it could deliver real benefits to disadvantaged women.

— Women and families who face additional difficulties are likely to benefit particularly from increased contact and support from health professionals and support workers both before and after the birth of a baby.

— Additional breastfeeding support from health professionals and greater Government financial support for establishing peer support groups is vital to give more women from disadvantaged communities the opportunity to breastfeed their baby.

— Greater investment in the health of low birth weight babies by introducing a low birth weight baby allowance paid with child benefit (and disregarded for means tested benefits) for the smallest babies for during their first and most vulnerable year of life.

3. MINORITY ETHNIC GROUPS, REFUGEES AND ASYLUM SEEKERS AND THOSE FOR WHOM ENGLISH IS NOT THE FIRST LANGUAGE

Health professionals need appropriate training in order that consideration for women's needs from different ethnic groups is recognised and respected. For example, in areas where there is a high population of African women who are affected by genital mutilation, midwives with specialist training should be used, eg at Guy's and St Thomas' NHS Trust in London. Women from other areas should be able to access these specialist services. Where a woman does not want to be looked after by male health professionals, her wishes should be respected and accommodated.

All women using maternity services in the UK should have access to information about pregnancy, birth and in early parenthood, the services provided and the choices available to them. There are particular challenges for women and families who do not have English as their first language. There is an urgent need to employ more interpreters to ensure that women can communicate with health professionals without relying on their partner, child or an NHS employee who happens to speak their language to act as a go between. Information leaflets should be available in main community languages and further work is needed to develop alternative formats, such as video, CD and cassette tape. Setting up community mothers schemes and employing health advocates may also be effective. In areas of large non-English speaking populations, parentcraft classes should be offered in other languages.

Recommendations:

— Interpretation facilities to be available in all maternity units serving ethnic minority populations for use during pregnancy, birth and the postnatal period.

— Ensuring that the benefits system allows all pregnant asylum seekers to receive sufficient financial or direct support for an adequate pregnancy diet.

— Ensure adequate funding is allowed for the production of information leaflets/videos/audiocassettes in other languages appropriate to the local population. These should be part of service planning, rather than an afterthought.

Mothers in Exile: maternity experiences of asylum seekers in England

A Crying Shame: pregnant asylum seekers and their babies in detention

4. THOSE LIVING IN POVERTY

For those women who are living in economically deprived circumstances, several issues are key in terms of their health and that of their children. Ensuring that they can afford good, nutritional food whilst pregnant and breastfeeding is vital and the revised Healthy Start scheme needs to take account of this.

There are many issues including poor housing that impact negatively on poor women and their children, but by continuing to pay those under 25 years of age a lower rate of benefit, this is being made worse. For those who are in families that are working, but on low incomes, it would be beneficial for Child Tax Credits and /or Child Benefit to apply from pregnancy rather than from the birth of a child. It would allow women more flexibility to afford a better diet and to look after themselves whilst pregnant.

Attending antenatal appointments and classes may be costly and difficulty where affordable and convenient public transport is lacking. This discourages those who would most benefit from being seen by health professionals attending appointments. Ensuing that women and their partners are aware of measures to help them with transport costs is key. In addition, in areas of high deprivation, it may be beneficial to take services to women in local health centres or their own homes rather than them having to travel. In the deprived Sighthill area of Edinburgh, such a scheme has been operating for nearly 30 years and there has been an important reduction in local perinatal mortality rates. [34]

Recommendations:

— Benefits for those with children under 25 should be equalised with those above that age.

— A winter fuel payment for families with a baby under one (as payable to pensioners), or a weekly fuel premium in means-tested benefits would help prevent damp and cold housing that contributes to many infant illnesses.

— Child Tax Credits and/or Child Benefit to apply from confirmation of pregnancy rather than when the baby is born.

— Travel costs need to be taken into consideration and new outreach systems of reaching women should be considered.

5. HOMELESS

For pregnant women or new parents who are homeless and living in temporary accommodation, this stressful time is likely to be made worse. Access to proper and clean facilities for bathing and cooking are likely to be the highest priority for families in that situation. Key to ensuring that a healthy baby is born is the mother's diet during pregnancy and having access to cooking facilities is vital. When the baby is born, if the mother is not breastfeeding, she needs to be able to make the baby's feeds in a clean environment or else the baby's health is more likely to suffer with problems such as gastro-enteritis.

Babies who are living in sub-standard temporary accommodation are more likely to be ill due to damp and cold accommodation and lack of play facilities mean that accidents are more likely.

With the proposed distribution of Healthy Start vouchers to disadvantaged women being by post, there are real concerns that women in temporary or insecure accommodation will not get the vouchers.

Recommendations:

— There should be minimum standards set for temporary accommodation housing pregnant women and those with young children including provision of a well-equipped kitchen with food storage, adequate play space, prevention of overcrowding and standards of cleanliness, warmth and safety.

— Local authorities and housing associations should give priority to housing pregnant women and those with small children.

Lives on hold: homeless families

6. DOMESTIC VIOLENCE

It is estimated that one in four women suffer domestic violence at some point in their lives, and pregnancy is often the trigger for violence to start or the point at which it becomes worse. A 2002 study of pregnant women at Hull Royal Infirmary found that one in six women had suffered domestic violence whilst pregnant. [35]Violence during pregnancy is associated with premature birth, low birth weight, foetal injuries to limbs and organs, placental abruption and premature spontaneous rupture of the membranes. [36]

Research on whether routine screening of women for domestic violence by health professionals is effective is limited and sometimes contradictory. As contact with health professionals is an opportunity for the woman to disclose violence against her, more research needs to be done in this area to establish whether it can help or harm women.

Recommendations:

— Improve training on domestic violence for midwives and health visitors.

— Increase funding for domestic violence refuges which are suitable for pregnant women and young babies.

— More backing for research to look at the benefits or negatives of routine screening for domestic violence.

7. MENTAL HEALTH PROBLEMS

In every 1,000 births, 100-150 women will suffer a depressive illness and one or two women will develop a puerperal psychosis. [37]If women suffer mental health problems during pregnancy and in the postnatal period, there is growing evidence about the effect it will have on the relationship between the mother and baby, and on the baby's future mental health and well-being. Boys are at particular risk of developing behavioural problems. [38]Therefore training in looking for symptoms and having the time to talk to women is important. Problems with lack of staff and staff time, by midwives, GPs and health visitors can have a detrimental effect on the types of services they are able to offer women and as a consequence, on the health of the baby. Women who are identified at greater risk of developing mental health problems may benefit from additional postnatal visits, interpersonal therapy and/or antenatal preparation. [39]

The ultimate action by a woman with severe mental health problems may be to attempt suicide. How health and social services work together to identify and prevent maternal deaths from suicide is crucial. The 2000-01 Confidential Inquiry into Maternal Deaths found that 25% of deaths of women in the period from pregnancy up until a year after the birth of the child were suicides. There is a clear need for investment in specialist psychiatric services, working with other health and social services, to identify, treat and support women with mental health problems.

A study of 480 new mothers found that the two key risk factors for postnatal depression were lack of a confidant(e) and low income. Women who both lived in poverty and lacked a confiding relationship were 19 times more likely than usual to develop postnatal depression. [40]

Recommendations:

— Investment in multi-disciplinary teams of health professionals and social workers who are immediately called in if a woman is thought to be at risk of mental health problems.

— Investment in specialist mother and baby units for those with severe postnatal illness so that all women, in whatever part of the country they live are within reasonable distance of a unit. Some women will not want to be with their baby whilst they are getting better, but facilities should be there to allow the mother and baby to be together, whilst not being too far from family, friends and their support network.

8. LEARNING AND PHYSICAL DISABILITIES AND SENSORY IMPAIRMENT

There is a long way to go before access to maternity services is equal for women and men with disabilities. Often they experience prejudice and are not treated with the dignity and respect afforded to non-disabled people. Women and men with sensory impairment or learning disability often experience difficulties accessing information about pregnancy, birth, baby feeding and early parenting. For some parents, videos or audio cassettes may be useful. For women who are wheelchair users, it is often difficult to find out which services would best meet their needs and to gain access to hospital buildings. During labour and afterwards, flexible arrangements and adjustable furniture is needed, so women can be as independent and comfortable as possible. After the baby has been born, an adjustable or low-level cot is important, as well as easy access to the toilet and bathroom. Facilities should be equally accessible for wheel-chair using fathers. For women with a sensory impairment, chronic condition or physical disability, access to a birth pool for use during labour, or support for a home birth or to use a midwife-led unit may make all the difference to their experience.

Pregnancy and childbirth are times when a woman can have a whole range of experiences from having enhanced well-being—including feeling extra good about herself as nurturing, productive, and capable—to feeling pushed around, disempowered and a failure. It is particularly important to avoid imposing inappropriate or unwanted treatment on women with sensory impairment or a physical or learning disability. Feeling in control of her own body and decisions about her care, or able to choose who and when to delegate some of that responsibility, is really important. There is often a tendency in a medicalised system for women with additional needs to be treated as high-risk and have additional monitoring and medical interventions which may not be wanted or needed. When women feel they lose control and are not treated with kindness, respect and dignity during childbirth, their self-esteem can be damaged, in some cases leading to post-traumatic stress disorder. Additional social support and the best opportunity to have a normal birth may enhance women's well-being, enabling them to feel positive about themselves and more confident in future as a parent.

Recommendations:

— Disabled service users should be involved in the planning and monitoring of services to ensure that facilities meet their needs.

— A national library providing sources of pregnancy, birth, baby feeding and early parenting information in a variety of formats should be resourced and information distributed widely to maternity services.

— A senior midwife should have designated responsibility for ensuring the needs of women with physically or learning disabilities or sensory impairments are met. The role should involve liaison within the multi-disciplinary health and social care team, providing care for individual women, advising on plans and policies within units, and training and supporting colleagues.

— All staff should have undergone equal opportunities training to ensure that all users of the maternity services are treated equally.

9. YOUNG MOTHERS AND FATHERS

Young parents can feel particularly isolated and classes and schemes specifically aimed at them have been shown to have positive benefit. Young women are more likely to have a low birth weight baby and are less likely to breastfeed, so particular help needs to be given to this group of women to ensure they have good information about healthy eating in pregnancy and support with breastfeeding. Sure Start schemes have been an excellent way of reaching out to young mothers and we strongly support the scheme's expansion and growth.

Recommendations:

— Further role out of Sure Start schemes to reach more young mothers and fathers in more locations.

— Informal community groups for young pregnant women and young parents can provide vital information about the processes of pregnancy and birth, and about what services and choices are available. They can make a real difference to self-esteem, create opportunities for mutual support, and have a positive impact on breastfeeding rates. Young fathers who are supported in their role can benefit personally, as well as supporting their partner and being available for their baby.

April 2003

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