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Health in Pregnancy Grant - The NCT response to current proposals
The National Childbirth Trust (NCT) is a charity and membership organisation with over 72,000 members across the UK. Our strength comes from the dedication of our volunteers, who work through our network of branches to provide and support local services, training and evidence-based information for parents, families and health professionals. We are trusted and respected by health professionals and governments as an organisation that represents the needs of parents.
The NCT wants all parents to have an experience of pregnancy, birth and early parenthood that enriches their lives and gives them confidence in being a parent.
The NCT offers information and support in order to give every parent the chance to make informed choices and wants to ensure universal access to our services and activities. In addition to our service provision function we campaign vigorously to improve maternity care and ensure better services and facilities for new parents.
The NCT contends that maternity and early parenting services should be designed around parents' needs and specifically aim for the transition to parenthood to be a positive experience for men and women.
We believe that the way that society supports those becoming parents during pregnancy, birth and the first years of parenthood have major implications for the future and well-being of the population.
The health and well-being of mothers and children are central to the health and well-being of society. The NCT welcomes the proposed new Health in pregnancy grant which has been established in recognition of the importance of maternal and early neonatal health for the future health of the whole community.
Universal benefits
Article 27 of the United Nations Convention on the Rights of the Child declares that children have a right to 'a standard of living adequate for the child's physical, mental, spiritual, moral and social development'. It points out that parents or others responsible for the child have primary responsibility, but that governments should assist parents. This makes it clear that society as a whole has a responsibility towards children.
The NCT supports universal benefits to support pregnant women and families with children, in addition to targeted financial support, for the following reasons:
· High take up rates - Child benefit reaches more children living in poverty than any other benefit or tax credit. · Ease of administration - universal benefits have fewer administrative or technical difficulties than means tested benefits or tax credits. · Avoidance of the poverty trap - Increases in universal benefits related to children benefit children in low-income families directly, as they are not offset against child tax credits and do not vary according to work opportunities. [1] · Paid to the mother - Money going directly into the mother's purse is more likely to benefit her and children in the family. This is particularly important as women are still economically disadvantaged. Weekly median individual income for all women in 2004/05 was just 55 per cent of that for all men (£173 vs. £315). The average woman working full-time is paid 17% less an hour than a man - and 38% less if her job is part-time. In addition, it is estimated that 30,000 women lose their jobs for being pregnant every year. · Sensitive and responsive - Universal benefits remove anxiety among people regarding whether they will qualify and whether it is worth applying. In addition they have the redistributive advantages of: · Lifecycle balancing. Most people have children at some point, and it is a time when needs are higher and income tends to be lower; so a universal pregnancy grant would help to redistribute resources (and the tax contribution) over the lifecycle.
· Intergenerational balancing. Since everyone - childless people, as well as those with children - will benefit in due course from the productivity of children being born now, society should share the cost of those children with their parents, as an investment by us all in the next generation. The vast majority of developed countries have some form of cash benefit and/or tax arrangement, paid to all families, to take account of the presence of children in households.
The NCT supports the payment of the Health in Pregnancy grant as a universal benefit. Widespread support NCT is a member of End Child Poverty, an alliance of more than 90 children's charities, welfare organisations, social justice groups, faith groups, trade unions and others concerned about the unacceptably high levels of child poverty in the UK, which campaigns for the eradication of child poverty in the UK. The final report of Get Heard[2] exercise included a section on participants' priorities in terms of financial help for low-income families.[3] The first item in the list, drawn up on the basis of report-backs from that exercise, was an increase in child benefit. The case for the importance of improving life chances for children has been made powerfully by the Commission on Life Chances and Child Poverty set up by the Fabian Society. It made a strong argument for shifting the balance back from tax credits to child benefit, to 'allow both elements to work more effectively alongside each other.'[4] It also argued that this would help families who have experienced insecurity as a result of, for example, administrative difficulties with the new tax credits. The Work and Pensions Select Committee, in its report on child poverty, argued that: "The national strategy on child poverty should reassert the commitment to retain universal child benefit uprated in future to maintain and enhance its real value as one of the foundations of all future support for children."[5] The NCT believes that the Health in Pregnancy grant should be developed as an extension of Child Benefit and paid as a universal benefit.
Impact of poverty and diet on future health
Proposals to tackle poverty need to recognise the pivotal role of low birth weight and a poor start to life as a primary cause of poor school performance, ill health and probably behavioural problems that pass from one generation to the next. This cycle traps communities in poverty.[6]
The evidence indicates that, if dietary intervention is to have an impact on birth weight and outcomes for the baby in later life, it should be started as early as possible. Appropriate interventions addressing inequalities at the preconception stage are most likely to be effective.[7] A detailed study of 44 nutrients in the diets of women in pregnancy reported that maternal nutrition early in the pregnancy was a stronger predictor of low birth weight than diet or micronutrient supplement in the last trimester.[8] In fact some adverse indications such as anaemia in mothers can take up to 6 months to improve, even when women are provided with supplements.[9] Women in the South West of England with self-assessed greater difficulty in affording food had lower intakes of protein, fibre, vitamin C, niacin, pyridoxine, iron, zinc, magnesium and potassium than did women with little or no difficulty. They were more likely to use cooking and spreading fats with a high saturates content, and less likely to eat fish, fruit, vegetables and salad. In a multivariate analysis including parity and smoking status, financial difficulty was found to have no significant relationship with birth weight after 32 weeks gestation.In spite of this, there are some indications that diet during pregnancy can influence children's development. It is clear that folic acid status in early pregnancy influences the development of neural tube defects in some women[10]. In this country fish consumption during pregnancy has been associated with improved results in children's cognitive development, even after adjusting for factors such as the age and education of the mother, whether she breastfed, and the quality of the home environment. After multivariable logistic regression including 28 potential confounders assessing social disadvantage, perinatal factors and diet were adjusted for, low maternal seafood intake during pregnancy was associated with lower increased verbal intelligence quotient (IQ) p=0.004, and lower social behaviour, fine motor, communication, and social development scores.[11] In addition, children whose mothers ate oily fish during pregnancy were more likely to have good eyesight than were children whose mothers did not eat oily fish.[12] However, there is a dearth of research in industrialised countries related to effective mechanisms for improving women's nutritional status either prior to pregnancy, during pregnancy or in the interpregnancy period. [13] Not surprisingly, the campaigns to encourage women to increase their folic acid intake prior to conception were more successful in reaching the older, more affluent, and higher social class women. This lack of evidence should not prevent innovative proposals and action to address the problem, but it necessitates careful evaluation. There should be an explicit hypothesis and both the process and desired outcomes should be assessed. The NICE Maternal and Child Nutrition group point out: "There is a lack of intervention studies and evaluations providing process and qualitative data. This is needed so that the effective components of an intervention can be assessed and replicated on a wider scale." [14] The NCT recommends that the Government should be explicit about what it intends to achieve through the Health in Pregnancy grant, that this objective should be realistic on the basis of existing evidence and knowledge about physiological and social processes and that the process and outcome effects of the new grant are evaluated in independent research studies. Research is also needed on a range of socio-economic and educational interventions designed to improve the health and well-being of childbearing women and babies (e.g. studies to improve birth weight, reduce prematurity, improve diet during pregnancy, improve health status prior to pregnancy, etc.)
Timing of payment
If the intention of the grant is to improve women's health in pregnancy and the health and life chances of babies, the proposal to pay the grant from 25 completed weeks of pregnancy does not take account of the evidence described above.
The Department of Health has set an explicit PSA target for all women to have started their antenatal care by the 12th week of pregnancy. (PSA Delivery Agreement 19) Indicator 4 states that 'The percentage of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy' will be monitored. The rationale for identifying this as a key performance indicator is that 'Women who are able to access maternity services for a full health and social care assessment of needs, risks and choices by 12 completed weeks of their pregnancy will have the full benefit of personalised maternity care and improve outcomes and experiences for mother and baby.' It is known that a high proportion of mothers and babies with poor pregnancy outcomes attend late and/or rarely attend for antenatal care.
Consideration should be given to starting the Health in Pregnancy payment once a woman has started her antenatal care, which should be by 12 completed weeks of pregnancy. There is an established precedent that benefits can be paid from early in pregnancy as Healthy Start vouchers are made available from 10 weeks. Linking the payment to starting antenatal care would provide a positive incentive to attend for antenatal care, and would reinforce key messages about having an early health and social needs assessment, and the importance of self-promoted health and regular antenatal care appointments.
We do not consider the concern about payments made to women who have a miscarriage or termination of pregnancy to be a valid reason for not paying the grant from 12 weeks.
· Most women who do not intend to continue their pregnancy do not enrol for antenatal care. · More than 89% of terminations and 98% of miscarriages take place before 13 weeks.[15] · Many late abortions are consequent upon the detection of foetal abnormalities.
The NCT recommends payment of the Health in Pregnancy Grant from as early in pregnancy as possible to have the maximum possible effect on improving maternal diet during pregnancy. This would certainly be possible to administer from around 12 completed weeks of pregnancy if linked to the PSA target of all pregnant women expecting to have a baby starting their antenatal care by 12 weeks. Healthy Start scheme
The NCT campaigned for the reform of the Welfare foods scheme and welcomed the introduction of Healthy Start vouchers which enable eligible pregnant women and eligible families with a child aged under 4 years to buy milk, fruit and vegetables. We agree with the NICE group on Maternal and Child Nutrition that "The vouchers are likely to have a greater impact, however, if their monetary value is increased." [16]
The NCT recommends that the value of the Health Start vouchers is increased.
Requirement for a health professional to provide advice
The text of the Bill refers to the women receiving "advice on matters relating to maternal health from a health professional". The NCT and the relevant health professional bodies, including the RCGP and the RCM, pointed out when the Healthy Start vouchers were planned, that these health professionals were not experts in tailoring dietary advice to individuals and would need additional training. This was promised, in line with the implementation of the Healthy Start scheme, but never delivered.
Again NICE point out: "Confusion about national nutrition policy relating to mothers, infants and children needs to be addressed. It is also necessary to help women who are preparing for pregnancy to understand the long-term consequences of poor nutrition during pregnancy on their child's health. There is a need to address professional education in these areas and agree competencies for practice."
The NCT recommends that the Government commits ring-fenced funding alongside introduction of the Health in Pregnancy grant to nutrition training for health professionals.
Regular payments vs lump sum
Child benefit is paid weekly or monthly directly to the mother. This means that women can rely on it as a regular supplement to the household income for the payment of day-to-day expenses such as food and fuel costs. A lump sum would appear less likely to be used for weekly or daily costs, including food, and more likely to be spent on one-off payments for larger items. Following a recent visit to Australia, Professor Debra Bick of Thames Valley University informed the NCT that in Australia single payments to parents in pregnancy have been coined 'plasma payments' as they are typically used to purchase flat-screen TVs.
Universal benefits increase uptake, are cheap to administer and do not create worry about having to pay money back if women, or their partner, are in work for a few weeks or months.
The NCT believes that the Health in Pregnancy payments should be paid on a weekly or monthly basis as an extension of Child Benefit so that they are most likely to be used to increase the budget for regular household expenses, increasing the likelihood of there being more income available for a nutritious diet during pregnancy.
January 2008 [1] End Child Poverty, Ten for a Million Charter, ECP. 2005 [2] 'Get Heard' was a participatory exercise in which a large number of people with direct experience of poverty throughout the UK developed ideas at workshops to feed into the next National Action Plan on Social Inclusion, for 2006-08. [3] Get Heard, Get Heard! People living in poverty contribute to the National Action Plan on Social Inclusion 2006-2008, UK Coalition Against Poverty, 2006 (project supported by the European Commission, Oxfam and the Department for Work and Pensions) [4] Commission on Life Chances and Child Poverty, Narrowing the Gap, Fabian Society, 2006, p185 [5] House of Commons Work and Pensions Select Committee, Child Poverty in the UK, Second Report, Session 2003-04, HC 85, Vol 1, The Stationery Office, 2004, recommendation 22. [6] Crawford MA. The inequality of health: women will eliminate poverty. The primary cause of poverty is at the start of life. 2007. [7] Draft guidance to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. NICE public health programme guidance 3. 2007 [8] Doyle W, Crawford MA, Laurance BM, Drury P.. Dietary survey during pregnancy in a low socio economic group. J. Hum. Nutr. 1982; 36A: 95 106. Doyle W, Wynn HA, Crawford MA and Wynn, SW. Nutritional Counselling and supplementation in the second and third trimester of pregnancy, a study in a London population. J. Nutr. Med. 1993; 3: 249 256. [9] Doyle W, Srivastava A, Crawford MA, Bhatti R, Brooke Z, Costeloe KL. Inter-pregnancy folate and iron status of women in an inner-city population. Br J Nutr 2001; 86(1):81-87. [10] Czeizel AE. Folic acid and the prevention of neural-tube defects. N Engl J Med. 2004 May 20;350(21):2209-11; [11] Hibbeln JR, Davis JM, Steer C, et al. Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): an observational cohort study. Lancet. 2007 Feb 17;369(9561):578-85. [12] Williams C, Birch EE, Emmett PM, Northstone K; Avon Longitudinal Study of Pregnancy and Childhood Study Team. Stereoacuity at age 3.5 y in children born full-term is associated with prenatal and postnatal dietary factors: a report from a population-based cohort study. Am J Clin Nutr. 2001 Feb;73(2):316-22. [13] Draft guidance to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. NICE public health programme guidance 3. 2007 [14] Ibid [15] www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_075697 [16] Draft guidance to improve the nutrition of pregnant and breastfeeding mothers and children in low-income households. NICE public health programme guidance 3. 2007
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