Memorandum by The Royal College of Midwives
(WP 61)
The Royal College of Midwives (RCM) is the professional
association and trade union representing 95% of all practising
midwives in the United Kingdom. The vast majority of midwives
work within the NHS, and the RCM is recognised in every Trust
that provides a midwifery service.
In submitting evidence to the Committee, the
College has confined its comments to those areas of expertise
represented in its staff and membership.
MIDWIVES INVOLVEMENT
IN PUBLIC
HEALTH
Good maternity care is key to providing good
public health and the RCM firmly believes that pregnancy and early
childhood should be put at the heart of the Government's public
health agenda. Intervention early on can make a real difference
to the health of the baby long term and can reduce the need for
action later in life. For example:
— breastfeeding has been shown (amongst
many other things) to reduce the instances of childhood obesity
and allergies;
— reducing exposure to tobacco smoke
while pregnant reduces the chances of a low-birth weight baby;
low birth weight babies have been shown to be at risk from a variety
of long term health problems including heart problems and respiratory
infections. In addition babies raised in environments where smoking
occurs are at an increased risk of respiratory problems and sudden
infant death; and
— pregnancy provides an ideal time
to work with mothers and families to improve their health behaviours.
Healthy choices made in pregnancy can often continue after birth
and be taken up by the whole family. This provides an excellent
example to children as they grow up and can break cycles of bad
health behaviours within families.
Midwives already do a great deal to address
health issues surrounding birth and pregnancy and will provide
advice and guidance on a number of issues such as diet and nutrition,
exercise and smoking in pregnancy. The RCM's response to the Government's
consultation "Choosing Health" outlined some of the
specific projects which maternity services across the UK are undertaking
to improve the health of pregnant women.
However, concerted action is also needed from
the Government if real improvements are to be made. The RCM has
welcomed many of the proposals in the Government's White Paper
and believes that they represent appropriate and effective ways
of achieving the Government's goal of ensuring the NHS acts to
improve peoples overall health as well as treating those with
an illness. In particular the RCM believes that the Government's
proposal to introduce more children's centres is an excellent
way of ensuring an integrated approach to maternity service care.
Providing that this is done in a way which recognises the value
which each group of professionals can bring to the service, then
it should work to provide real joined up attitude to the care
for a particular child and family.
However, there are some areas of the white paper
where the College believes that the action proposed by the Government
is either inappropriate or inadequate to produce real improvements.
This evidence focuses on those areas and provides specific recommendations
that the RCM believes the committee should make to improve the
Government's proposals.
Areas where we feel changes are needed are,
increased action to:
— reduce pregnant women's exposure
to tobacco smoke;
— provide a real increase in breastfeeding
rates and the length of time women continue to breastfeed; and
— improve the diet of mothers, particularly
those in lower income brackets.
THE GOVERNMENT
SHOULD INTRODUCE
A TOTAL
BAN ON
SMOKING IN
ENCLOSED PUBLIC
PLACES
Exposure to tobacco smoke whilst pregnant places
a number of risks on to a pregnant woman and her baby. Along with
the risks which any smoker faces such as increased chance of cancer
and heart disease, tobacco smoke has additional risks to the unborn
foetus. Smoking when pregnant increases the risk of spontaneous
abortion and placenta praevia. Smoking also increases risks of
pre-term delivery and means there is an increased risk that the
baby will be born at a low birth weight. Low birth rate babies
are put at a significant risk of a number of diseases and disabilities
including heart problems and respiratory infections it can also
be linked to delayed cognitive development.
The RCM have long recognised that midwives have
a role to play in helping pregnant women to give up smoking. In
2003 the RCM produced its own guide for its members—"Helping
Women Stop Smoking—a guide for midwives". This provided
midwives with information as to why pregnant women should be encouraged
to give up smoking, practical tips of how to approach the subject
with women, and identified the sources of help available to midwives
involved in helping women to quit.
However, exposure to environmental tobacco smoke
remains a key concern. Firstly because woman exposed to smoky
environments will find it harder to give up as she will be more
likely to be tempted to smoke and secondly because research shows
that exposure to environmental tobacco smoke can have harmful
effects on the unborn infant. Action on smoking and Health (UK)
recently collected together a summary of some of the evidence
relating to the effects of exposure to passive smoking[115].
This highlighted evidence from the WHO which identifies passive
smoking as a potential risk factor in causing low birth weight.
This is backed up by a number of other scientific studies including
one published in 1999 in Evidence Based Obstetrics and Gynaecology[116]
which indicated that:
"Chronic exposure to environmental tobacco smoke
during pregnancy results in a mean decrease in birth weight of
25-30g and a 10-20% increase in the risk of low birth weight or
small for gestational-age infants".
The public health white paper recognises the
risk of exposure to environmental tobacco smoke and proposes introducing
a ban on smoking in all enclosed public places and workplaces
(paragraph 76). Unfortunately, it undermines this principle by
proposing exceptions to this ban for some licensed premises which
do not prepare or serve food and private clubs—the RCM fails
to see the reason for this exception and calls on the committee
to recommend its removal.
If the proposal was to be adopted in its current
form it would mean that pregnant women would still be exposed
to environmental tobacco smoke (particularly so if they are employed
there) and the risks this represents. The only option for a pregnant
woman in these circumstances would be to avoid going to places
where smoking was not prohibited. This is an unreasonable and
unrealistic option for a number of reasons:
— firstly, because many women do not
know that they are pregnant until 8-12 weeks into the pregnancy,
so during these first stages the women may be unknowingly exposed
to the risks of environmental tobacco smoke, with no opportunity
to make an effort to avoid it;
— secondly, because it is unrealistic
to expect a pregnant woman not to take a full and active part
in social activities with friends and family during her pregnancy;
and
— thirdly because, if employed in such
an environment the reasonable adjustments required by the employer
may not be possible and the woman would face the choice of giving
up her job or continuing with all the attendant risks.
Pregnant women do not have an illness and pregnancy
itself is a normal physiological condition. Therefore pregnant
women should on the most part be encouraged to continue to take
an active part in their community, rather than be restricted from
large areas of it because of the risk to the unborn child.
MORE RADICAL
ACTION IS
NEEDED TO
INCREASE UK BREAST
FEEDING RATES—WHICH
REMAIN TOO
LOW
The positive effects of breastfeeding on the
long term health outcomes of both mother and baby are well documented.
Research has shown that artificially fed babies are at increased
risk of gastro-intestinal infection, respiratory infections, necrotising
enterocolitis, urinary tract infections, ear infections, allergic
infections and diabetes and later cardiovascular disease. Mothers
who breastfeed also benefit and have a decreased risk of breast
cancer, ovarian cancer, and hip factures and bone density problems.
Despite these advantages the levels of breastfeeding
in the UK remain extremely low. Only 69% of women initiate breastfeeding
and the number of women who breastfeed for the recommended six
months after the birth is only 21%. These rates compare unfavorably
with many other developed countries, for example countries such
as Sweden and Norway have breastfeeding initiation rates of 98%
and about 55% continue to exclusively breastfeed to six months
of age.
Evidence suggests that women do not breastfeed
in the UK for a variety of reason, often related to difficulties
getting breastfeeding established or with milk supply. However,
there is worrying evidence that one of the possible reasons is
that they feel uncomfortable about doing so outside of the privacy
of their own homes. During the passage of the recent Breastfeeding
etc Act in Scotland, evidence was cited which suggested that there
is a stigma attached to breast feeding a baby in a public place.
For example:
— the Health promotion agency for Northern
Ireland recently published research on attitudes to breastfeeding
in NI, this revealed that 54% of respondents felt that breastfeeding
should always take place in a private place; [117]and
— a Scottish study conducted in 1999,
surveyed a group of parents (half of which had breast fed their
baby themselves). Of these nearly a third thought that a mother
should not feed her baby in a public restaurant. [118]
Midwives have a clear role in making women aware
of the health benefits of breastfeeding and helping women who
want to breastfeed get breastfeeding established. The College
has developed a number of resources aimed at encouraging breastfeeding
and we will be playing an active role in breastfeeding awareness
week from 8 to 14 May 2005.
However, this work needs to backed up by support
from the Government. The Government's new extended maternity leave
rights have been a very positive measures which helps women to
breastfeed for longer and the public health white paper also contains
some policies to encourage more breastfeeding. These are:
— providing that infant formula milk
will no longer be made available through healthcare premises;
and
— providing further restrictions on
the advertising of infant formula (assuming agreement of legislation
at an EU level).
However, the RCM believes that these proposals
do not go far enough to address the problem. The RCM would like
to see more support from the Government for breastfeeding to back
up the advice provided by professionals this action should particular
aim to promote breastfeeding as a social norm. The committee should
recommend that the Government takes the following action:
— conducting media campaigns to include
television adverts like those used in Norway and more recently
in Scotland to improve public awareness and acceptance of breastfeeding;
and
— clarifying the law in the UK to make
it clear that it is illegal to prevent a women from breastfeeding
in a public place—similar to the legislation which has been
passed in Scotland and in a number of states in the US.
GOOD NUTRITION
AND A
HEALTHY LIFESTYLE
IN PREGNANCY
IS ESSENTIAL
TO ENSURE
A HEALTHY
INFANT, BUT
THE WHITE
PAPER REFORMS
ARE UNLIKELY
TO PRODUCE
SIGNIFICANT IMPROVEMENTS
Ensuring good health while pregnant is essential
in ensuring a healthy infant. It is therefore essential that pregnant
women are encouraged to maintain a general healthy lifestyle throughout
pregnancy with good nutrition and appropriate exercise.
Poor nutrition in pregnancy is a particular
cause for concern. Some studies suggest that poor diet is the
second biggest cause of low birth weight in babies in developed
countries[119].
By providing the mother with advice on good nutrition during pregnancy
there is also the possibility that she will establish good eating
habits which will be passed on to her children, thus working to
improve the health of society in the long term.
Pregnant women need to be encouraged to eat
a varied diet which contains all of the essential nutrients. In
particular pregnant women should be encouraged to consume foods
which are high in calcium and plenty of fruit and vegetables—which
provide essential vitamins and minerals. In common with the rest
of the population pregnant women are advised that they should
eat a minimum of five portions of fruit and vegetables a day.
However evidence suggest that adults in general are getting nowhere
near that amount and younger women of child bearing age are even
less likely to eat the recommended allowance than women in the
50s or 60s—women aged between 25 and 34 eat on average only
2.4 portions a day, compared to 3.8 for older women[120].
An area of particular concern is the diet of
low income families and teenage mothers. Women in a household
in receipt of benefit have on average only 1.9 portions of fruit
and vegetables per day compared to 3.1 in non benefit households[121].
Research done by Maternity Alliance into the diet consumed by
teenage mothers confirmed that many teenage mothers (who often
have less money) have a poor diet, including high sugar levels
and low fruit and vegetable intake[122].
In this survey lack of money was often cited as reason for missing
meals or eating cheap unhealthy, filling food like biscuits or
chips. Women aged 18-24 on income support receive around £11
less per week than women over 25, women aged 16-17 can receive
even less income. This contributes significantly to the poverty
levels and thus poor diet of teenage mothers.
Clearly pregnant women will benefit equally
from many of the proposals contained in the public health white
paper generally aimed at improving the overall health and diet
of the nation. Pregnant women will benefit from having greater
information about the content of their food and from the advice
of health trainers/Health direct if they require further assistance.
However, given the special nature of pregnancy specific reforms
are needed to ensure that all pregnant women are given the best
opportunity of having a healthy diet.
The public health white paper recognises this.
It recommends working to improve the diet of pregnant women in
low income families through the healthy start scheme. This will
provide pregnant women, breastfeeding mothers and parents of young
children with vouchers that can be exchanged for fresh fruit and
vegetables, milk and infant formula. However, while recognising
the good intentions behind this scheme the RCM believes that it
is inadequate to produce real improvements in maternal nutrition.
This is because:
— mothers often find the use of vouchers
patronising and often will not feel comfortable about using them
because of the social stigma which is attached;
— the vouchers will not be accepted
in places where people on low incomes are most likely to shop—most
notably markets and local stores; and
— the vouchers will not be worth enough
to produce real improvements in diet—currently the vouchers
are only worth £2.80 a week.
Instead the RCM calls on the committee to recommend
a different approach aimed both at promoting good diet during
pregnancy in a way which is acceptable to expectant mothers, and
improving income in the lowest income families so that they can
afford to eat better.
The RCM would make the following specific recommendations:
— A scheme aimed at putting free fresh
fruit into all places where expectant mothers and young families
are likely to go, for example children's centres or doctors waiting
rooms.
— Paying mothers under the age of 24
the full rate of income support, increasing the income level of
the most deprived group to provide the money available to buy
healthy food.
CONCLUSION
The Royal College of Midwives believes that
the Government's public health white paper represents some positive
proposals which should go along way to implementing the Government's
public health goals. However, in the areas of smoking, breastfeeding
and general health in pregnancy the Government has failed to introduce
the radical reforms necessary to produce real improvements and
further reforms are necessary—as outlined in this response.
The RCM would be happy to attend the committee
to give oral evidence to expand on the issues contained in this
evidence in more detail.
February 2005
www.healthpromotionagency.org.uk/resources/breastfeeding/breastfeedingresearch.htm
115 International Consultation on Environmental
Tobacco Smoke (ETS) and Child Health; WHO Tobacco Free Initiative;
WHO/ NCD/TFI/99.10; 1999. Quoted by ASH UK in Passive Smoking:
A summary of the evidence May 2004. Available at www.ash.org.uk Back
116
Exposure to environmental tobacco smoke during pregnancy is
associated with decreased birth weight; Windham G C; Eaton
A; Hopkins B. Evidence for an association between environmental
tobacco smoke exposure and birthweight: a meta-analysis and new
data (Paediatr Perinat Epidemiol 1999; 13: 35-57. Commentary by
Khan, Khalid in Evidence based Obstetrics and Gynaecology (Harcourt,
2000) 2,5. Back
117
Health Promotion Agency for Northern Ireland. (2003) Breastfeeding
in Northern Ireland: a summary report on knowledge, attitudes
and behaviour. Available at: http: Back
118
Shepherd C K, Power K G and Carter H. (1999) Examining the
correspondence of breastfeeding and bottle-feeding couples' infant
feeding attitudes. Journal of Advanced Nursing 31(3) pp 651-660. Back
119
Kramer M S, 1987 Determinants of Low Birth Weight: Methodogical
Assessment and Meta-Analysis Bulletin of the World Health
Organisation vol. 65(5) pp 663-737. Back
120
Office of National Statistics 2002 National Diet and Nutrition
Survey-adults aged 19 to 64 years available at www.food.gov.uk/multimedia/pdfs/ndnsprintedreport.pdf Back
121
See above. Back
122
Maternity Alliance/Food Commission, 2003 Good Enough to Eat-The
diet of pregnant teenagers available at www.maternityalliance.org.uk/documents/good_enough_to_eat.pdf Back
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